HospitalInspections.org

Based on interview, record review, and review of facility policy it was determined the facility failed to develop and implement a nursing plan of care related to the supervision of patients in the Emergency Department (ED) that followed the facility's policy for suicide screening and prevention for five (5) of twenty-five (25) patients (Patient #3, Patient #4, Patient #5, Patient #22, and Patient #23) when patients presented with Suicidal Ideation.

The findings include:

Review of the facility's policy titled "Suicide Screening and Prevention," revised February 2018, revealed any patient admitted with a diagnosis of overdose or other suicidal behavior did not require an initial screening for Suicidal Ideation since Suicidal Ideation was established. The policy further stated that these patients would be monitored on a one-to-one basis and the physician was notified for psychiatric evaluation if not already requested. Continued review of the policy revealed one-to-one monitoring required staff members to be in near proximity and within visual range at all times. Further review of the policy revealed staff would document on a flow sheet every fifteen (15) minutes on the patients.

1. Review of the medical record for Patient #3 revealed the facility admitted the patient on 12/20/17 at 1:18 PM with diagnoses that included Salicylate Overdose complicated by illicit drug use.

Continued review of the medical record revealed upon triage at 1:10 PM Patient #3 was brought to the facility via Emergency Medical Services (EMS) after the patient reported he/she had taken 18-20 aspirins within 90 minutes. Continued review of the medical record revealed Patient #3 was administered Charcoal 50 milligrams (mg) orally at 1:35 PM. The medical record revealed that nursing staff documented at 3:40 PM that Patient #3 was lying in bed with his/her eyes closed and at 4:30 PM Patient #3 was given a supper tray and ate 100 percent of the meal. The facility transferred Patient #3 at 4:45 PM via EMS to another acute care facility. There was no documented evidence that Patient #3 was placed on one-to-one monitoring and no evidence of a 15-minute check flow sheet in the medical record.

2. Review of the medical record for Patient #4 revealed the facility admitted the patient on 03/16/18 at 5:03 PM with diagnoses that included Acute Psychosis with Suicidal Ideation.

Continued review of the medical record revealed upon triage on 03/16/18 at 5:02 PM, Patient #4 was brought in from home via EMS and stated that he/she had been "shooting up meth." Patient #4 was experiencing auditory and visual hallucinations and ruminations with repetitive statements. The patient verbalized a suicidal attempt and a plan. Continued review of the medical record revealed the ED physician completed a Medical Screening Exam at 9:36 PM. Nursing staff documented a vital sign check at 5:02 PM and 10:15 PM. Nursing staff documented at 5:15 PM, 7:00 PM, 7:45 PM, 11:37 PM, and at 12:07 AM. The facility transferred Patient #4 to another acute care facility via EMS on 03/17/18 at 12:07 AM. There was no documented evidence that Patient #4 was placed on any type of Suicidal Monitoring (one-to-one) and no evidence of a 15-minute check flow sheet in the medical record.

3. Review of the medical record for Patient #5 revealed the facility admitted the patient on 01/22/18 at 7:37 PM with a diagnosis of Schizophrenia with Suicidal Ideation.

Continued review of the medical record revealed upon triage on 01/22/18 at 7:35 PM, Patient #5 presented to the ED with complaints of hearing voices telling him/her to hurt his/her father and seven (7) year old sibling. Patient #5 stated "I want to blow my brains out to make the voices stop." Continued review of the medical record revealed the ED physician completed a Medical Screening Exam at 8:00 PM. Nursing staff documented at 8:30 PM, 9:20 PM, and 11:01 PM. The facility transferred Patient #5 to another acute care facility via EMS on 01/23/18 at 11:01 PM. There was no documented evidence that Patient #4 was placed on any type of Suicidal Monitoring (one-to-one) and no evidence of a 15-minute check flow sheet in the medical record.

4. Review of the medical record for Patient #22 revealed the facility admitted the patient on 10/02/17 at 9:01 PM with a diagnosis of Suicidal Ideation.

Continued review of the medical record revealed upon triage on 10/02/17 at 8:55 PM, Patient #22 presented to the ED with complaints of Suicidal Ideation. Patient #22 presented with a plan and a strong feeling of wanting to die. Continued review of the medical record revealed the ED physician completed a Medical Screening Exam at 10:21 PM. Nursing staff documented at 9:45 PM, 11:26 PM, 12:05 AM, 2:20 AM, 2:55 AM, and 4:10 AM. The facility transferred Patient #22 to another acute care facility via EMS on 10/03/17 at 4:27 AM. There was no documented evidence that Patient #4 was placed on any type of Suicidal Monitoring (one-to-one) and no evidence of a 15-minute check flow sheet in the medical record.

5. Review of the medical record for Patient #23 revealed the facility admitted the patient on 06/08/17 at 12:22 AM with diagnoses of Depression, Post Traumatic Stress Disorder, and Suicidal Ideation.

Continued review of the medical record revealed upon triage on 06/08/17 at 12:21 AM, Patient #23 was brought to the ED via law enforcement officers after making threats to harm himself/herself. Further review of the medical record revealed the ED physician completed a Medical Screening Exam at 1:37 AM. Nursing staff documented checks at 12:21 AM, 12:30 AM, 1:28 AM, 1:39 AM, 2:12 AM, 2:48 AM, 3:01 AM, 3:24 AM, 4:01 AM, 4:45 AM, 5:14 AM, 5:46 AM, 6:04 AM, 6:45 AM, 7:05 AM, and 7:25 AM. There was no documented evidence that Patient #4 was placed on any type of Suicidal Monitoring (one-to-one) and no evidence of a 15-minute check flow sheet in the medical record.

Interviews with Registered Nurse (RN) #1 on 03/22/18 at 3:22 PM and RN #2 on 03/22/18 at 3:54 PM revealed that they both worked in the Emergency Department. Interviews revealed that they had a room they used when it was available for behavioral health patients and placement in this room was determined when triaged and the plan of care was developed. RN #1 stated that they did monitor those patients as best they could; however, they did not put them on one-to-one monitoring and did not document on them every fifteen minutes. RN #1 stated that there were only two (2) RNs on duty at a time in the ED and they could not monitor a patient one to one and provide care for the other patients they were assigned. Continued interviews revealed that the RNs were not aware of the facility's procedure that required each patient that complained of suicidal ideation or overdose required one-to-one monitoring in the ED.

Interview with the Director of Nursing (DON) on 03/22/18 at 4:15 PM, revealed that RNs were required to chart hourly on their patients in the ED; however, her expectation was that if a patient required more monitoring, then nursing staff should conduct that monitoring and document that monitoring was completed according to facility policy/procedure. The DON stated the facility did have a behavioral health room in the ED they could utilize when needed. Continued interview with the DON revealed that patients were not placed on one-to-one monitoring as per facility procedure. The DON stated the facility's policy addressed patients that were admitted to the facility and did not specifically address patients that were in the ED and the nursing staff was probably not aware of the facility's procedure.

Based on record review, interviews, and review of facility policy it was determined the facility failed to ensure the medical record was maintained for every individual evaluated or treated in the hospital. The facility failed to have documented physician orders for laboratory studies and for medications administered for three (3) of twenty-five (25) sampled patients (Patient #4, Patient #6, and Patient #12). In addition, the facility failed to have completed nursing assessments for two (2) of twenty-five sampled patients (Patient #6 and Patient # 12). Furthermore, the facility failed to ensure that written and/or verbal physician orders for seventeen (17) of twenty-five (25) sampled patients had been dated, timed, and authenticated by the ordering physician as soon as possible (or on their next visit) (Patient #1, Patient #2, Patient #4, Patient #5, Patient #7, Patient #8, Patient #10, Patient #11, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, Patient #21, Patient #22, and Patient #23).

Review of the medical records of sampled patients revealed the ordering practitioner had not always dated, timed, and/or authenticated the written and/or verbal orders. In addition, physicians were not dating and timing written orders. Furthermore, physicians were signing prefilled order sheets but were not choosing a medication to order from the ones listed on the form. Also, the facility failed to ensure a History and Physical was completed for one (1) of twenty-five (25) sampled patients (Patient #1). (Refer to A0454, A0458, and A0467.)

Based on interviews, review of Rules and Regulations of the Medical Staff Bylaws, review of facility policy, and medical record review, it was determined the facility failed to ensure that written and/or verbal physician orders for seventeen (17) of twenty-five (25) sampled patients (Patient #1, Patient #2, Patient #4, Patient #5, Patient #7, Patient #8, Patient #10, Patient #11, Patient #13, Patient #14, Patient #15, Patient #16, Patient #17, Patient #18, Patient #21, Patient #22, and Patient #23) had been dated, timed, and authenticated by the ordering physician as soon as possible (on their next visit).

Review of the medical records of sampled patients revealed the ordering practitioner had not always dated, timed, and/or authenticated the written and/or verbal orders. In addition, physicians were not dating and timing written orders. Furthermore, physicians were signing prefilled order sheets but were not choosing a medication to order from the ones listed on the form.

The findings include:

Review of the facility's policy titled "Medical Center Bylaws Rules & Regulations Pertaining to Record Completion," undated, revealed all medical entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing the service. Continued review of the policy revealed that orders given over the telephone shall be signed by the person to whom dictated, with the name of the physician. A physician must sign such orders as soon as possible. The policy did not define "as soon as possible."

Review of the facility's policy titled "Processing Physicians' Orders," revised January 2015, revealed verbal orders shall be signed by the physician on his/her next visit, or as soon as possible either electronically or handwritten with date and time.

1. Review of the medical record for Patient #1 revealed the facility admitted the patient on 01/27/18 with a diagnosis of Pneumonia.

Review of the Physician Orders revealed verbal orders were given on 01/30/18 at 10:34 AM and 01/29/18 at 4:31 PM by Physician #3. These orders were not authenticated by the ordering physician until 02/02/18. Further review revealed a verbal order was given on 01/28/18 at 12:41 PM by Physician #5; this order was not authenticated by the ordering physician until 02/09/18.

2. Review of the medical record for Patient #2 revealed the facility admitted the patient on 01/12/18 with a diagnosis of Multifocal Pneumonia.

Review of the Physician Orders revealed Physician #1 gave five (5) verbal orders on 01/12/18 at 1:18 PM. These orders were not authenticated until 01/17/18. Further review of the orders revealed Physician #9 gave verbal orders on 01/14/18 at 12:50 PM and 6:23 PM that were not authenticated until 02/09/18.

3. Review of the medical record for Patient #4 revealed the facility admitted the patient on 03/16/18 with diagnoses that included Acute Psychosis with Suicidal Ideation.

Review of the Physician Orders revealed a "Physicians Order Sheet" in the medical record that was not completed and was not signed, dated, and timed.

4. Review of the medical record for Patient #5 revealed the facility admitted the patient on 01/22/18 with a diagnosis of Schizophrenia with Suicidal Ideation.

Review of the Physician Orders revealed a "Physician Order Sheet" that had orders for laboratory studies of a Complete Blood Count (CBC), Comprehensive Panel, Thyroid-Stimulating Hormone (TSH) level, Alcohol (ETOH) level, and a urinalysis (UA) along with orders for Geodon (antipsychotic medication) 20 milligrams (mg); however, the order sheet was not signed, dated, or timed.

5. Review of the medical record for Patient #7 revealed the facility admitted the patient on 03/21/17 with diagnoses that included Anemia, Lung Cancer, and Dehydration.

Review of the Physician Orders revealed orders that were written by Physician #6 on 03/21/17; these orders were untimed. Further review revealed verbal orders that were given on 03/21/17 at 8:14 PM by Physician #7. These orders were not authenticated until 03/25/17; and a verbal order given on 04/04/17 at 9:53 PM by Physician #7 was not authenticated until 04/14/17. Continued review of the orders revealed verbal orders given on 04/04/17 at 10:47 AM and at 6:27 PM were not authenticated until 04/09/17 by Physician #6. A verbal order given on 03/23/17 at 11:01 AM was not authenticated until 03/27/17.

6. Review of the medical record for Patient #8 revealed the facility admitted the patient on 03/27/17 with diagnoses that included Chest Pain, Diabetes, and Coronary Artery Disease.

Review of the Physician Orders revealed a "Physician Order Sheet" that had orders for laboratory studies of a Complete Blood Count (CBC), Comprehensive Panel, Thyroid-Stimulating Hormone (TSH) level, Alcohol (ETOH) level, and Urinalysis (UA), as well as orders for an electrocardiogram (EKG), and a Portable Chest X-Ray by Physician #8 that were unsigned, undated, and untimed. In addition, Physician #8 gave a verbal order on 03/27/17 at 7:50 PM and it was not authenticated until 09/05/17. Continued review of the medical record revealed a verbal order given on 03/30/17 at 10:48 AM by Physician #6 was not authenticated until 04/08/17.

7. Review of the medical record for Patient #10 revealed the facility admitted the patient on 11/28/17 with a diagnosis of Contracture of the right palm.

Review of the Physician Orders revealed "Post Anesthesia Care Unit (PACU) Orders" written on 11/28/17 by Physician #10 were signed; however, the physician failed to choose a pain medication (Morphine 1-3 mg IVP every 10 minutes as needed; Demerol 10-50 IV (intravenous) every 10 minutes as needed; Lortab 5-7.5 oral every 4-6 hours as needed; or Toradol 30 mg IVP as needed one time); and a nausea medication (Anzemet 12.5 mg IVP (intravenous push) may repeat once; Phenergan 12.5 mg IVP as needed may repeat one time; and Zofran 4 mg IVP as needed may repeat one time) from the medication listed on the order form.

8. Review of the medical record for Patient #11 revealed the facility admitted the patient on 02/07/18 with a diagnosis of Febrile and Rule out Kawasaki's Syndrome.

Review of the Physician Orders revealed a "Physician Order Sheet" that Physician #11 had signed; however, he failed to complete the order sheet and had not dated or timed his signature.

9. Review of the medical record for Patient #13 revealed the facility admitted the patient on 01/02/18 with a diagnosis of Acute Bronchitis.

Review of the Physician Orders revealed a verbal order given on 01/10/18 at 4:07 PM by Physician #6, which was not authenticated until 01/19/18.

10. Review of the medical record for Patient #14 revealed the facility admitted the patient on 03/15/18 with a diagnosis of Epigastric Pain.

Review of the Physician Orders revealed a "Post Anesthesia Care Unit (PACU) Order" written on 11/28/17 by Physician #2 that was signed. However, the physician failed to choose a pain medication (Morphine 1-3mg IVP every 10 minutes as needed; Demerol 10-50 IV every 10 minutes as needed; Lortab 5-7.5 oral every 4-6 hours as needed; or Toradol 30 mg IVP as needed one time); and a nausea medication (Anzemet 12.5 mg IVP may repeat x one; Phenergan 12.5 mg IVP as needed may repeat one time; and Zofran 4 mg IVP as needed may repeat one time) from the medication listed on the order form.

11. Review of the medical record for Patient #15 revealed the facility admitted the patient on 03/15/18 with a diagnosis of Left Carpal Tunnel Syndrome.

Review of the Physician Orders revealed a "Post Anesthesia Care Unit (PACU) Order" written on 11/28/17 by Physician #10 that was signed; however, the physician failed to choose a pain medication (Morphine 1-3mg IVP every 10 minutes as needed; Demerol 10-50 IV every 10 minutes as needed; Lortab 5-7.5 oral every 4-6 hours as needed; or Toradol 30 mg IVP as needed one time); and a nausea medication (Anzemet 12.5 mg IVP may repeat x one; Phenergan 12.5 mg IVP as needed may repeat one time; and Zofran 4 mg IVP as needed may repeat one time) from the medication listed on the order form.

12. Review of the medical record for Patient #16 revealed the facility admitted the patient on 11/20/17 with a diagnosis of Alleged Assault and Rape. Review of the Physician Orders revealed a "Physician Order Sheet" for laboratory studies that included a Complete Blood Count (CBC), Comprehensive Panel, Urine Drug Screen (UDS), and a Urinalysis (UA) that was signed by Physician #8; however, the physician failed to date and time the order.

13. Review of the medical record for Patient #17 revealed the facility admitted the patient on 01/26/18 with diagnoses that included Cerebrovascular Accident with Aphasia/Aphagia.

Review of the Physician Orders revealed a "Physician Orders for Hospice Patients" form that Advanced Practice Registered Nurse (APRN) #1 had signed and dated; however, she failed to time the orders.

14. Review of the medical record for Patient #18 revealed the facility admitted the patient on 11/15/17 with a diagnosis of Status post Right Knee Replacement.

Review of the Physician Orders revealed a verbal order given by Physician #6 on 11/16/17 at 8:45 AM that was not authenticated until 12/02/17. Further review revealed a verbal order given by Physician #9 on 11/16/17 at 10:18 PM that was not authenticated until 11/22/17.

15. Review of the medical record for Patient #21 revealed the facility admitted the patient on 02/09/18 with diagnoses that included Acute Bronchitis and Congenital Heart Disease.

Review of the Physician Orders revealed verbal orders given by Physician #6 on 02/09/18 at 6:48 PM and 02/10/18 at 10:35 AM that were not authenticated until 03/11/18.

16. Review of the medical record for Patient #22 revealed the facility admitted the patient on 10/02/17 with a diagnosis of Suicidal Ideation.

Review of the Physician Orders revealed a "Physician Order Sheet" with orders for laboratory studies that included a Complete Blood Count (CBC), Comprehensive Panel, Alcohol (ETOH) level, Salicylate level, Acetaminophen (APAP) level, and a Urinalysis (UA). The order sheet was signed by Physician #8, but the physician failed to date and time the order.

17. Review of the medical record for Patient #23 revealed the facility admitted the patient on 06/08/17 with diagnoses of Depression and Post Traumatic Stress Disorder.

Review of the Physician Orders revealed a "Physician Order Sheet" signed by Physician #11 with orders for laboratory studies that included a Complete Blood Count (CBC), Comprehensive Panel, Prothrombin Time (PT), Alcohol (ETOH) level, Acetaminophen (APAP) level, and a Urinalysis (UA). Although the order was signed by Physician #11, the physician failed to date and time the order.

Interview with the Quality Director on 03/21/18 at 2:00 PM revealed that she was not aware of the issue of the physicians not signing verbal orders. The Quality Director stated it was the facility's expectation that the physicians sign their verbal orders as soon as possible. Further interview revealed she was aware that the facility had not defined what "as soon as possible" meant.

Interview with Physician #2 on 03/22/18 at 3:37 PM revealed he was the Chief of Surgery and that he knew he signed the PACU order sheet; however, he stated that nursing staff always came and obtained a verbal order before administering any type of medication in Post-Operative Care. He stated he did not know why the facility still utilized the "paper" form since going with all electronic records.

Interview with Physician #1 on 03/22/18 at 2:35 PM revealed that she was the Chief of Staff and that it was her understanding that verbal orders had to be signed twenty-four (24) hours after being given. Continued interview revealed that all physicians should know that they had to sign, date, and time all orders whether they were written or electronic orders.

Based on interviews, record review, and review of facility policy it was determined the facility failed to ensure a History and Physical was completed for one (1) of twenty-five (25) sampled patients (Patient #1).

The findings include:

Review of the facility's policy titled "Medical Center Bylaws Rules & Regulations Pertaining to Record Completion," undated, revealed all records must contain a medical history and physical examination completed and documented no more than thirty (30) days before or twenty-four (24) hours after admission.

Review of the medical record for Patient #1 revealed the facility admitted the patient on 01/27/18 with a diagnosis of Pneumonia. Continued review of the medical record revealed the history and physical was completed on 01/29/18 by Physician #3 (48 hours after admission to the facility).

Interview with the Quality Director on 03/21/18 at 2:00 PM revealed that Medical Records tracks the timeliness of history and physicals and it was documented and the physician was informed.

Interview with Physician #1 on 03/22/18 at 2:35 PM revealed that she was the Chief of Staff and she knew that history and physicals had to be completed within twenty-four (24) hours of admission and the facility monitored the completion for history and physicals. Further interview revealed that all physicians attempted to complete history and physicals in a timely manner.

Based on record review, interviews, and review of facility policy it was determined the facility failed to have documented physician orders for laboratory studies and for medications administered for three (3) of twenty-five (25) sampled patients (Patient #4, Patient #6, and Patient #12). In addition, the facility failed to have completed nursing assessments for two (2) of twenty-five (25) sampled patients (Patient #6 and Patient # 12).

The findings include:

Review of the facility's policy titled "Medical Center Bylaws Rules & Regulations Pertaining to Record Completion," undated, revealed all orders for treatment should be documented.

1. Review of the medical record for Patient #4 revealed the facility admitted the patient on 03/16/18 with diagnoses that included Acute Psychosis with Suicidal Ideation.

Review of the Physicians Orders revealed a "Physicians Order Sheet" in the medical record that was not completed, was not signed, and not dated or timed. Continued review of the medical record revealed results for laboratory studies that included: chemistry, hematology, urinalysis, toxicology, microbiology, and a chemistry profile. However, there was no documented evidence in the medical record for physician orders for these laboratory studies.

2. Review of the medical record for Patient #6 revealed the facility admitted the patient on 01/16/18 with a diagnosis of Cardiac Arrest.

Review of the "Code Blue Sheet" dated 01/16/18 and timed 7:15 PM revealed the facility administered Epinephrine (the dose was not documented) at 12:35 PM, 12:39 PM, 12:42 PM, 12:46 PM, and 12:49 PM and Sodium Bicarbonate (the dose was not documented) at 12:36 PM, 12:45 PM, and 12:48 PM. There was no documented evidence in the medical record that Physician #8 signed any order for these medications.

3. Review of the medical record for Patient #12 revealed the facility admitted the patient on 01/23/18 with diagnoses of Chest Pain and Non-ST Elevation Myocardial Infarction (NSTEMI - a type of heart attack).

Continued review of the medical record revealed results of laboratory studies that included a CBC (complete blood count), Basic Metabolic Panel (BMP), Prothrombin Time/International Normalized Ratio (PT/INR), as well as results for a Chest X-Ray and an EKG. However, there was no documented evidence in the medical record for physician orders for these laboratory studies and tests. Further review of the medical record revealed Patient #12 was administered Aspirin 324 mg (milligrams) orally on 01/23/18 at 10:35 PM; however, there was no documented evidence in the medical record for a physician's order for Aspirin.

Interview with Registered Nurse (RN) #2 on 03/22/18 at 3:54 PM revealed that she worked in the Emergency Department (ED) where Patients #4, #6, and #12 were provided care. RN #2 stated that the ED had a cardiac order set that included all the orders for labs and the aspirin for Patient #12 and that was what should have been in the medical record. Continued interview revealed the only way the ED could get the lab down to draw labs without the electronic order was to call for a "stat" draw.

Review of the facility's policy titled "Nursing Assessment/Reassessment," effective December 2017, revealed all patients received an initial assessment which was begun and completed in triage, or at any point of entry. The policy stated that the assessment addressed immediate needs in the areas of physical functioning, psychological, educational, and social care.

4. Review of the medical record for Patient #6 revealed the facility admitted the patient on 01/16/18 with a diagnosis of Cardiac Arrest.

Review of the "Emergency Room Assessment" form dated 01/16/18 at 12:32 PM revealed nursing staff completed the "initial triage" part of the assessment; however, the sepsis screening, the medical history, surgical history, social history, medications, general appearance, respiratory assessment, cardiovascular assessment, pain assessment, neurological assessment, skin and wound assessment, circulatory assessment, gastrointestinal assessment, genitourinary assessment, musculoskeletal assessment, EENT (Eyes/Ears/Nose/Throat) assessment, OB/GYN (Obstetric/Gynecological) assessment, and psychosocial assessment were not completed.

5. Review of the medical record for Patient #12 revealed the facility admitted the patient on 01/23/18 with diagnoses of Chest Pain and NSTEMI (Non-ST Elevation Myocardial Infarction).

Review of the "Emergency Room Assessment" form dated 01/23/18 at 10:17 PM revealed nursing staff completed part of the nursing assessment; however, the respiratory assessment, cardiovascular assessment, pain assessment, neurological assessment, skin and wound assessment, circulatory assessment, gastrointestinal assessment, genitourinary assessment, musculoskeletal assessment, EENT (eyes/ears/nose/throat) assessment, OB/GYN (obstetrics/gynecological) assessment, and psychosocial assessment were not completed.

Interview with Registered Nurse (RN) #2 on 03/22/18 at 3:54 PM revealed that she worked in the Emergency Department. RN #2 stated that Patient #6 came in "coding" and the nurse would have to go back and complete her documentation for Patient #6. RN #2 stated that when a patient expired there was a "not applicable" box in each section that the RN could use to complete the assessment. RN #2 stated the assessment should never be left blank.

Interview with the Director of Nursing (DON) on 03/22/18 at 4:15 PM revealed that it was part of her duties to oversee the ED. The DON stated that a nursing assessment should never be left blank. Continued interview with the DON revealed that the Cardiac Order Set was in the electronic record system and she did not know why those patients did not have orders for tests in their medical records.