HospitalInspections.org

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Based on interview, record review, document review, and review of the hospital's policies and procedures, the hospital failed to ensure that emergency care was managed and provided in accordance with professional practice recommendations or requirments.

Failure to manage and deliver emergency care in line with professional standards can lead to unsafe, uncompetant, and low quality emergency care.

Findings include:

1. Failure to demonstrate integration of it's emergency services with other hospital departments.

2. Failure to validate successful completion of an emergency nurse's orientation.

3. Failure to confirm staff completion of annual mandatory education.

4. Failure to promote validation of triage competency skills for ED nurses that perform the triage functions.

5. Failure to recognize patient's ESI categories which lead to improper triage decisions, patients without ongoing monitoring and without required physical reassessments.

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Based on interview and review of hospital policies and procedures, the hospital failed to demonstrate integration between the Emergency Department and other hospital departments.

Failure to demonstrate integration of its emergency services within other hospital departments can adversely affect the health and safety of patients who require emergency care.

Findings include:

1. Review of a hospital's policy titled, "Divert: Full Capacity Protocol (Surge Full Capacity Protocol)," dated 12/14 stated that the Full Capacity Protocol will be initiated when the main department of the ED is full and admitted ED patients are waiting in-hospital bed placement. The policy's main focus is to maintain effective inpatient bed capacity, minimize the time the hospital is on divert, and reduce the ED length of stay. The Full Capacity performance measures and evaluation, contained in the policy included performing electronic medical record review, "review reports and daily census for temporary bed assignment. Also, 100% chart review by unit management for appropriate placement, amount of time in temporary beds, and patient outcomes."

2. During an interview on 2/20/18 at 10:00, Staff J, Interim Chief Nurse Executive, stated that the hospital initiates the Full Capacity Protocol, 1 to 2 times a week during "flu season." Hospital management did not provide evidence of medical record review for: appropriate bed assignment, amount of temporary bed time or patient outcomes analysis or evaluations. It was unclear if hospital quality improvements were in place to address ED metrics and patient flow analysis.

3. A review of the hospital's grievance log on 2/21/18 found five (5) ED-related practice complaints on one of the three campuses. Two complaints had been referred to the ED manager for actions. At 10:00 AM, during an interview with Staff H, Interim ED Director, stated that ED leadership was aware of only one of the two incidents and only aware of three complaints overall. Documented evidence of ED-specific actions taken in response to this or other quality activities at this location could not be found or produced.

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Based on interview, record review and review of hospital policies and procedures, the hospital failed to ensure emergency staff appropriately prioritized and treated patients identified as emergent (Patient #1), urgent (Patient #2) Emergency Severity Index (ESI) scores.

Failure to appropriately prioritize incoming patients can lead to very ill or very high- risk patients waiting for an assessment, diagnostic testing, monitoring, and treatment.

Reference: Gilboy N, Tanabe T, Travers D, Rosenau AM. Emergency Severity Index (ESI): A Triage Tool for Emergency Department Care, Version 4. Implementation Handbook 2012 Edition. AHRQ Publication No. 12-0014. Rockville, MD. Agency for Healthcare Research and Quality. November 2011. "In general, care of ESI level-2 patients should be rapidly facilitated and the role of the charge nurse or flow manager is to know where these patients can be placed in the treatment area on arrival. All level-2 patients are still potentially very ill and require rapid initiation of care and evaluation. The triage nurse has determined that it is unsafe for these patients to wait. Patients currently may be stable, but may have a condition that can easily deteriorate; initiation of diagnostic treatment may be time sensitive (stable chest pain requires an ECG within 10 minutes of arrival); or the patient may have a potential major life or organ threat. ESI level-2 patients are still considered to be very high risk."

Findings include:

1. Review of the hospital's policy titled, "Triage," dated 5/16 directs emergency staff to perform triage on all patients presenting to the emergency department (ED) for care. The policy details the ESI categories used to ensure consistent triage decisions. "Category 1 (Resuscitation). Conditions that are an imminent threat to life/limb ...Category II. (Emergent). Conditions that are a potential threat to life, limb, eyesight or function requiring rapid medical intervention ...Category III (Urgent). Many resources (2 or more) needed ..."

2. A review of 22 patient's medical records who received care in emergency services under CMS Certification Number 500129, revealed the following:

a. Patient #1 was a 66 year-old patient, who was transported by EMS on 1/5/18 at 12:30 PM, to the ED for complaint of chest pain. EMS personnel administered, under the tongue medication to help relieve her pain, plus one aspirin. When the ambulance arrived, the ED was observed to be on "Surge: Full Capacity Protocol," and due to no available ED exam rooms the patient was taken to the triage area within the ED waiting area. There a nurse triaged and identified the patient's ESI, acuity 2 (urgent). From reviewing the record, it was unclear if the patient remained in the triage area or waiting area. Initial vital signs were checked at 12:32 PM (time triage was completed) with a blood pressure measured at 144/90. An EKG (diagnostic test) was performed and reviewed by a provider at 12:43 PM. Blood testing was also collected at 1:05 PM. The patient's primary RN completed a "2nd assessment" at 2:26 PM, however no documentation was found related to chest pain reassessments, vital signs or ongoing cardiac monitoring. At 2:59 PM, the record showed pain medication order and given without documentation related to pain scale before or after administration. Vital signs were rechecked at 3:00 PM, with a blood pressure measured at 165/98. A nurse note entered at 3:35 PM, stated that "pain medication took away her pain ..." No reassessments were documented related to pain or physical status. The last vital sign entry was at 4:00 PM: blood pressure -153/102, pulse - 66. At 5:08 PM, it was noted that the patient was discharge and "taken out of ER in wheelchair," without a re-assessment (note blood pressure) or responsible individual accountable to the patient after she received a narcotic.

b. Patient #2 was a 52 year old female arrived at the ED at 12:43 PM on 2/19/18 complaining of a rash. Triage assessment at 12:45 PM found dizziness and a blood pressure of 175/91 and the patient was categorized ESI acuity 3 (urgent). The next documented assessment was at 8:45 PM at discharge. Documentation of an acuity change could not be found or produced. Interview with Staff K confirmed this finding.

3. During an interview on 2/20/18 at 4:50 PM, Staff H, Interim ED Director, stated that the acuity #2 patients should receive emergency care as soon as possible. These emergent patients should be monitored in the ED and reassessed every 2 hours. More critical patients should be reassessed every hour.

4. Interviews with two ED triage nurses revealed the following:

a. On 2/20/18 at 11:45 AM, an interview with Staff A, a triage nurse, revealed that she could not find or produce a written reference or policy defining triage category-based reassessment intervals for emergency department patients. This observation was acknowledged by Staff G and H.

b. On 2/23/18 at 9:30 AM, an interview with Staff K, a triage nurse, revealed that she could not find or produce a written reference or policy defining triage category-based reassessment intervals for emergency department patients. This observation was acknowledged by Staff F.

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Item #1 - Emergency Nurse Orientation

Based on interview, personnel file review and review of hospital documents, the hospital failed to ensure emergency staff participated in a comprehensive, individualized, position specific orientation, as outlined in the emergency department (ED) orientation checklist.

Failure to validate successful completion of a position specific orientation can lead to nurses inability to provide quality, competent, and safe emergency nursing care in accordance with professional practice requirements.

Reference: Emergency Nurses Association. Position Statement - Emergency Nurse Orientation. September, 2015. "Emergency nurses work in stressful, fast-paced environments where they integrate evidence-based knowledge, make rapid assessment, critical decisions, and life-saving intervention while prioritizing and multitasking. Emergency nurses therefore require a skill-set well beyond that necessary for nursing licensure one that is specific to their practice environment and the care of a wide variety of patients ...Successful completion of an emergency nurse orientation is based on each participant's ability to demonstrate competence by applying knowledge using critical thinking skills, and demonstrating proficient technical skills to provide safe, quality care."

Findings include:

1. Review of a hospital's document titled, "Scope of Services. Tacoma General Emergency Department," Dated: 2/18, showed that ED clinical competencies are determined by the staff role in the ED. They are identified by "patient population served, services rendered, on-boarding & orientation needs, regulatory requirements, skills that require repetitive competency assessment, introduction of new equipment & technology, professional requirements, plus on-going training needs." Includes a list of "Professional Standards," Emergency Nurses Association (ENA), ANA Standards for Nursing Practice, System & Hospital unit-specific references, and Lippincott Manual of Nursing."

a. Review of a hospital's document titled, "Position Specific Orientation Checklist Emergency Department Registered Nurse," dated 1/17, showed a list of "core competencies" that are specific to the ED. The document contains 8 pages with instructions noted on the front page, "Core competencies are essential skills, knowledge and behaviors that are required to perform the specified job. Assessment of an individual's competency may occur through observation of daily activities or observation & completion of specific skill validation/competency form as indicated ..." Each skill is listed followed by a column for "resource: policy (P), bundle (B), CBL (C), and multi-tube (M), followed by column marked, "assessment method by experienced staff: VR-verbally reviews skill, O-Observed performing skill, and SVF - completion of skill validation form." Last column is marked, "Date/Initial Met." The last page includes an area for the orientee's and preceptor (s) signatures. An area for the "Unit Specified Manager" to sign acknowledging that "The above procedures have been satisfactorily performed under the supervision of our staff." Followed by, "Your Unit Specified Manager will check your skills list and evaluate it for satisfactory achievement. At the end of your orientation period, your skills list will be reviewed for progress and you will receive an evaluation of your work."

2. A review of six (6) ED (Staff A, B, F, K, L, N) Registered Nurse Position Specific Orientation Checklists revealed the following:

a. The "Resource" columns were unmarked on 5 checklists. A resource for each skill was not identified.

b. The "Assessment Method" columns were unmarked on 5 checklists. Assessment methods were not identified.

c. Each checklist were observed without the ED manger's signature or date, acknowledging their review and satisfactory validation of the nurse's competencies.

d. The last column marked for, "Date/Initial Met." One individual's (Staff A) skills checklist was dated and initialed on the same date. The remaining skills checklist were observed to have vertical line drawn through the entire skills list with one initial and date.

e. Review of a contracted nurse's file (Staff N), assigned to staff the emergency department, showed a completed "General Site Orientation Checklist," but her file did not contain an "Emergency Department Specific Orientation Checklist."

3. During an interview on 2/21/18 at 4:50 PM, Staff G, Regulatory & Accreditation Manager, stated that the orientation checklists were incorrectly marked. All three columns should be completed with each skill dated and initialed upon skill validation.

Item #2 - Specialty Annual Mandatory Education

Based on personnel file review and review of hospital documents, the hospital failed to ensure emergency staff completed all specialty mandatory education as required, in 6 of 10 files reviewed (Staff A, B, C, D, E, F).

Failure to confirm completed mandatory education can lead to staff's inability to provide quality, competent, and safe emergency care in accordance with professional practice requirements.

Findings include:

1. Review of a hospital's document titled, "Job Title: Registered Nurse. Department: Acute Care Services ..." Dated: 7/08, showed that nurses applying for employment in the hospital's acute care units should hold, along with other qualifications, current Washington State RN licensure, one year experience in acute care setting (preferred), Current CPR certification, "ACLS or NALS, or PALS or TNCC certification, as required by facility or department, and certification in specialty area preferred."

a. Review of a hospital's document titled, "2017 Specialty Annual Mandatory Education, Emergency Department RN," showed a list of required education to be completed annually for ED nurses. Front page showed requirements divided into categories such as: "ED Specific CBL (computer based learning)" - lists 5 CBLs to register for and complete. Then there are POCT (point of care testing) to be completed on-line and demonstrate in person. Also included are "Life Safety & Licensure Requirements," that need to be renewed every 2 - 4 years depending on the education category. The back page showed 5 "Advanced Competency Program with Annual Validation Requirements." These are: "Procedural Sedation, Ventricular Assist Device-Tier Three (TG ED & Float RNs only), Ultrasound Guided IV Placement (GS & Covington only), Restraints -violent & non-violent, and Nurse Administered Nitrous Oxide (Mary Bridge only).

2. A review of ten (10) emergency nurses personnel file revealed the following:

a. Six (6) personnel files (Staff A, B, C, D, E, F) showed that their ED Annual Advanced Competencies (procedural sedation, ventricular assist device - tier three, and restraints) were not listed in their individual transcripts or completed during 2017.

b. One ED (Tacoma General) nurse's (Staff D) transcript showed a Basic Life Support card that expired December, 2014. An ED (Allenmore Hospital) nurse's (Staff F) transcript showed no evidence of completing Neonatal Resuscitation course as required under the life safety category.

Item #3 - Triage

Based on interview, personnel file review and review of hospital documents, the hospital failed to uphold triage competency skills for each registered nurse performing ED triage, as recommend by professional standards.

Failure to promote triage competency skills validation can lead to inconsistent triage decisions, treatment, and negative patient outcomes.

Reference: Emergency Nurses Association (ENA). Position Statement - Triage Qualifications & Competency, dated May, 2017. "The process of triage is best carried out by RNs with emergency nursing expertise who have completed a triage-specific educational program. Triage is a critical assessment process performed by a registered nurse or ARNP with a minimum of one-year of emergency nursing experience ...ED leadership ensures that RNs receive appropriate education and demonstrate the knowledge application and situational awareness required to successfully function in the role of triage nurse according to professional an accreditation standards."

Findings include:

1. During an interview on 2/22/18 at 10:00 AM, Staff I, ED Clinical Director, stated that an RN must have one year emergency experience to perform triage functions. A formal triage education is available through the MultiCare education system but not a mandatory course. The class focuses on the ESI triage algorithm and EMTALA.

2. A review of three emergency departments Scope of Services and RN job descriptions, managed under CMS Certification Number 500129, did not include statements supporting a formal triage-specific education program or ongoing triage competencies necessary to perform the triage process for emergency patients. No documentation could be found specific to a registered nurse having one year emergency experience in order to perform triage functions.

3. A review of ten (10) emergency nurses personnel file showed that four (4) nurses (Staff A, C, E, F) have not completed a formal triage course as observed in their educational transcripts.

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