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Based on observation and interview, the hospital failed to ensure the signage for EMTALA rights with respect to the examination and treatment for EMC and women in labor was posted conspicuously in the ED Triage area where the signage would likely be noticed by the individuals visiting the ED. This failure had the potential result in the individuals to not be aware of their rights to the examination and treatment in the event of an EMC.

Findings:

On 2/22/23 at 0940 hours, during the initial tour of the ED with the ED Director, an EMTALA signage was observed posted at the ambulance bay. Two posted EMTALA signages showing the patients' rights with EMC were observed on the wall of the waiting area by the admission area and at the ED treatment area.

However, there was no EMTALA signage conspicuously posted in the ED Triage area located behind the admission area where the patients were initially examined by the ED staff.

The ED Director was asked for the EMTALA signage at the ED Triage area. The ED Director could not show or locate an EMTALA signage posted at the ED Triage area.

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Based on observation, interview, and record review, the hospital failed to ensure an MSE was provided in a timely manner to determine whether or not an EMC existed for two of 21 sampled patients (Patients 1 and 20) as evidenced by:

1. For Patient 1, the ED staff did not assign an appropriate ESI level and did not ensure an MSE was performed in a timely manner based on the patient's chief complaint. In addition, the ED staff did not reassess Patient 1 as a minimum every two hours when the patient was assigned with ESI Level 5 and did not ensure Patient 1 was monitored appropriately while waiting for emergency service in the waiting room as per the hospital's P&P.

2. For Patient 20, the ED staff did not triage the patient as per the hospital's protocol related to the OB triage. In addition, the hospital's P&P related to triaging for OB patients was not reflecting the hospital's current practice.

3. The hospital did not ensure the ED staff competency and training as per the hospital's P&P.

These failures had the potential to result in poor clinical outcomes and serious adverse events to the patients in the ED.

Findings:

Review of the hospital's P&P titled Triage dated March 2021 showed in part:

* Scope: ED RN and emergency physicians.

* Purpose: to systematically and logically assign priorities of care to patients as they arrive to the ED; and ensure that every patient receives high quality, efficient, and appropriate medical care based on the medical need utilizing and established triage process.

* Policy: Triage involves a rapid patient assessment that provides an assignment of an acuity level for each patient presenting to the ED. The triage level is designed to minimize morbidity, disfigurement, pain, emotional distress, and client dissatisfaction with their emergency care.

* Procedure:

- Triage will be completed using the Emergency Severity Index (ESI) version 4 methodology. ESI levels include ESI Level 1(Resuscitation), ESI Level 2 (Emergent), ESI Level 3 (Urgent), ESI Level 4 (Semi-Urgent), and ESI Level 5 (Non-Urgent).

- ESI Level 1: The patient presents with the need for immediate (upon arrival) interventions that are categorized as life-saving. Vital signs are to be monitored continuously.

- ESI Level 2: The patient presents with a high-risk condition posing a potential threat to life, limb, or function and requires rapid medical intervention. Patient will be placed in the first available appropriate treatment area. The triage nurse will notify the charge nurse of these patients as soon as possible. Vital signs will be taken at a minimum of every 30 minutes until in a treatment area and condition is stabilized.

- ESI Level 3: The patient presents with a condition that could progress to a serious problem requiring emergency intervention. The vital signs of the patient may or may not be outside of the normal limit. Two or more resources are anticipated to treat this patient. Vital signs will be taken a minimum of every 60 minutes until assessed by the MD.

- ESI Level 4: The patient presents with a condition that has a low potential for deterioration or complications. One resource is respected to treat this patient. Vital signs will be taken at a minimum of every two hours until seen by the MD.

- ESI Level 5: These patients present with a condition that may be acute but is not urgent. The condition may be part of a chronic problem with or without evidence of deterioration. No resources are anticipated to be needed to treat this patient. Vital signs will be taken at a minimum of every two 2 hours.

- Triage Assessment and Documentation: A RN will interview and assess each patient upon arrival to prioritize incoming patients and to identify those who must be seen immediately. The remaining patients will be routed to the appropriate area for further evaluation and treatment.

- The Additional Triage Responsibility/Special Considerations: The triage nurse will monitor patients in the waiting room. The triage nurse and the charge nurse will work together to determine the priority of patients to be brought back to the treatment areas. To triage the Obstetric patient, staff will use the Triage of Obstetric Patient Policy.

- Triage Procedure: if the patient had an actual or potential life-threatening event taking place (ESI Level 1 or 2), the RN will take the patient immediately to a treatment area and give the bedside or charge nurse report. If the patient does not require emergent care (ESI Level 3, 4, or 5) and no bed available, the patient should be prioritized to be evaluated by the triage nurse. The triage nurse and/or the charge nurse are responsible to see that all ambulance patients are triaged to include vital signs and have the MD assess them as quickly as possible. The charge nurse or designee is responsible for the bed assignment of ambulance patients. The triage nurse and charge nurse are responsible for communicating information to patients and families waiting for disposition. The triage nurse is responsible for providing care and safety to patients arriving and waiting for emergency services in the waiting room.

1. Review of the hospital's P&P titled Emergency Room Coverage dated November 2020 showed in part:

* An Officer or agent of the Department of Security Services/Public Safety Department will be posted in or patrolling near the Emergency Department 24 hours a day and seven days a week unless dispatched to assist with an emergent situation.

* The Emergency Department remains open 24/7 to receive trauma patients, emergency patients and psych patients regularly. The continual possibility of violent actions by psych patients, patients in police custody or other agency is constant and concerning. The emergency department is a high risk area and must have a constant security presence.

Review of Patient 1's closed medical record was initiated on 2/16/23.

Patient 1's medical record showed Patient 1 was bought to the ED from a drug rehabilitation facility by the EMS on 1/4/23 at 1658 hours, with a complaint of "tremors and overall body pain s/p coming down from using Methamphetamines (a highly addictive stimulant)" and was discharged on 1/24/23 at 2042 hours. Patient 1 was bought back to the ED by the EMS on 1/5/23 at 0012 hours.

Review of the Triage Report electronically signed by RN 10 on 1/5/23 at 0338 hours, showed the following:

* Patient 1 was triaged on 1/5/23 at 0025 hours.

* The Patient Narrative section showed Patient 1 had bilateral foot pain from walking for weeks. Per EMT, the patient had hallucinated and was stating that people were after him. Patient 1 took "METH" (or methamphetamines) two days ago. The patient was here earlier for the same problem. The EMT picked up the patient from the outside of Restaurant 1.

* The Pain Assessment section showed Patient 1's pain level was 10.

* Patient 1's acuity or ESI level was "5."

Review of the Progress Note Inquiry dated 1/5/23 at 0300 hours, showed Patient 1 was found inside of the restroom by the waiting room area. The patient was on sitting position behind the door. The patient's back was leaning on the wall. The blanket was found around the patient's neck. The patient was pulseless and was not breathing. The patient's skin was cold and dry. The CPR was started.

Review of the Progress Note Inquiry dated 1/5/23 at 0432 hours, showed Patient 1 was bought to the ED Bed 2 per MD 1 at 0312 hours. Patient 1 was put on pads/monitor. The patient's heart rhythm was asystole.

Review of the Code Blue Record dated 1/5/23, showed the code was started at 0312 hours and ended at 0331 hours. Patient 1 was unconsciousness, was not breathing, was cyanotic, had no pulses, and had the dilated pupils when the Code Team arrived. The patient expired on 1/5/23 at 0331 hours.

There was no documented evidence showing the ED nursing staff had assessed Patient 1 at a minimum of every two 2 hours or on 1/5/23 at 0225 hours, as per the hospital's P&P.

Review of the hospital's document dated 1/5/23 at 0812 hours, showed on 1/5/23 at approximately 0305 hours, the PSO received the radio traffic for assistance to the ED lobby. Upon the arrival, the radio traffic changed to Code Blue. Once the PSOs arrived at approximately 0310 hours, the PSOs assisted the nurses and physician to lift Patient 1 into the medical bed and they started commencing CPR at that time. While checking the video footage, the PSO saw Patient 1 arrived by the paramedic at 0009 hours and was checked by a RN at 0017 hours. At approximately 0040 hours, a Code Blue was called over the speaker for a different patient who was brought in by the paramedic at 0045 hours; this Code Blue was not cleared until 0200 hours. During this time, the paramedic left Patient 1 alone at 0125 hours at which time Patient 1 went inside the ED lobby. Patient 1 was there until 0200 hours, then Patient 1 went inside the restroom. Patient 1 were there for about an hour. A RN came out to check on Patient 1 at 0305 hours, and Patient 1 was not responding to the RN's call. At this point, the RN notified the charge nurse and security. Patient 1 had hung himself from the back of the door with a sheet the patient had with him.

On 2/23/23 at 0730 hours, an interview was conducted with the triage nurse (RN 10) and change nurse (RN 2).

RN 10 was asked about the triage for Patient 1 on 1/5/23 at 0025 hours. RN 10 stated Patient 1 arrived at the ED via the EMT transportation, for his drug withdrawal. RN 10 stated Patient 1 complained of the foot pain and had the pain level of 10. RN 10 stated the patient complained about the foot pain but had no problem with walking. RN 10 stated RN 10 did not observe a wound or a skin opening on the patient's foot. RN 10 stated the patient had hallucination manifested by self-talking and kept looking on his back. RN 10 stated RN 10 evaluated the patient and assigned the ESI Level "5" to the patient. RN 10 stated the patient's ESI level should be higher. RN 10 stated RN 10 informed MD 1 the patient was in the ED in the afternoon and again came back to the ED. RN 10 stated RN 10 was not sure whether or not the MD had seen the patient. RN 10 stated it was about the same time when another patient with cardiac arrest arrived to the ED by the ambulance; and the ED staff went to the treatment area to assist with the CPR for that patient. RN 10 stated Patient 1 should be assessed every two hours for vital signs and chief complaint as per the hospital's P&P. RN 10 stated the RN saw the surveillance camera showing Patient 1 was in the waiting room at 0200 hours. RN 10 stated RN 10 did not go to the waiting room to assess Patient 1 or talk the patient about the delay in seeing physician as she should.

RN 2 was interviewed consecutively. RN 2 stated that was a busy night. RN 2 stated a patient with cardiac arrest arrived to the ED shortly after Patient 1 arrived to the ED. RN 2 stated the ED staff were occupied with the CPR for that patient. RN 2 stated RN 2 was doing multiple tasks. RN 2 helped to override the medications from Pyxis for the CPR, entered the physician's orders, and delivered medications. RN 2 stated RN 2 also kept his eyes on the surveillance camera to glance the patients who were in the waiting room. RN stated RN 2 did not know if Patient 1 was there or not. RN 2 stated RN 2 recalled Patient 1 arrived by the EMT transportation and was left on the gurney with EMT transporters in the ambulance bay. RN 2 stated after an hour, the EMT staff came to the ED treatment area and stated that they had to go and left Patient 1 in the waiting room. RN 2 stated it was the protocol for the EMT staff to watch their ED patients for an hour when the ED was not ready; after an hour, the ED staff had to take over whether the ED had capacity or not. RN 2 stated Patient 1 then stayed in the waiting room and was waiting to be placed in the ED bed. RN 2 stated the ED waiting room had a 360 degrees surveillance camera and a restroom. RN 2 stated it was the triage nurse to be responsible for a patient who was in the ED waiting room until the patient had assigned to a RN. RN 2 stated there was one physician who would be providing care for all ED patients. RN 2 stated the ED staff was made aware of Patient 1 was not in the ED waiting room about 0300 hours. RN 2 stated when RN 10 told RN 2 that MD 1 was looking for Patient 1 to perform the MSE, they would not locate the patient. RN 2 stated RN 10 went to check the restroom by the ED waiting room, the restroom door was locked. RN 2 used his own key, wiggled to unlock the restroom door. RN 2 felt the resistance from the back of the restroom door. RN 2 was finally able to open the restroom door and found Patient 1. RN 2 stated there was no security officer in the ED, the security officers might have been doing security rounds in the hospital. RN 2 stated it was always to have a security officer in the ED in the past. RN 2 stated RN 2 did not see a security officer in ED waiting room consistently. RN 2 stated normally, the ED staff checked patients hourly after triage. RN 2 stated the ED staff would be physically reassessing the patient every 2 hours for vital signs and chief complaint. RN 2 stated the ED staff would explain and apologize to the patient for the delay and provide the blanket to the patient if needed.

On 2/28/23 at 0736 hours, an interview was conducted with MD 1. MD 1 was asked for Patient 1's MSE. MD 1 stated he was aware that Patient 1 returned to the ED on 1/5/23, at midnight with the complaint of foot pain and hallucination and was not returned to the rehabilitation center where the patient originally came from. MD 1 stated Patient 1 should be assigned to the higher ESI Level and should not be assigned with ESI level "5" because the patient stated his foot pain was "10." MD 1 acknowledged Patient 1 was having substance withdrawn manifesting symptoms of the body pain. MD 1 was aware the EMT transporters were upset as they had to stay with the patient in the ambulance bay. When asked, MD 1 stated MD 1 did not perform MSE for Patient 1. MD 1 stated another patient with full arrest came to the ambulance bay when he walked out to the ambulance bay trying to see Patient 1. MD 1 stated MD 1 took the patient with full arrest to the ED treatment area and initiated the CPR. MD 1 stated during their ongoing CPR, the EMT staff came to the ED treatment area and told the ED staff that the EMT staff was upset and stated they had to leave. MD 1 stated the EMT staff moved Patient 1 to the ED waiting room; RN 2 signed off Patient 1 from the EMT. MD 1 stated that the CPR for the patient with full cardiac arrested was complicated; and it took a lengthy of time. MD 1 stated when the CPR for that patient was terminated, MD 1 went back to check all ED patients including Patient 1 and noticed Patient 1's name was on the board. MD 1 stated MD 1 questioned the ED staff where Patient 1 was. MD 1 stated MD 1 thought the patient might be go out to smoke; MD 1 went outside of the ED but did not see the patient. MD 1 stated the ED staff stated the patient might be in the restroom and the ED staff went to find the patient. MD 1 stated the restroom door was locked and it took some time for RN 2 to unlock the door. MD 1 stated then, the ED staff found Patient 1 hung himself with the patient's own sweater strapped on the restroom door control. MD 1 stated he did not perform the MSE for Patient 1.

On 2/28/22 at 1026 hours, an interview was conducted with RN 7. RN 7 was asked about Patient 1. RN 7 stated that night, she heard RN 10 sounded a patient who needed a bed and Patient 1 was wheeled in to Bed 2. RN 7 stated RN 7 was not aware of what happened to Patient 1 prior the CPR started for the patient. RN 7 stated RN 7 put the cardiac monitor on Patient 1, and it showed asystole. RN 7 stated MD 1 told RN 7 to use a towel to support the patient's neck; the patient had dilated and fixed pupils. RN 7 stated it would be helpful if security officer watched the ED patients who were in the ED waiting room when ED staff was occupied with patient care tasks. RN 7 stated the ED staff had to be more often and closely monitor their patient's location to ensure the patient's safety.

2. Review of the hospital's P&P titled Obstetrical Patients, Triage of dated July 2021 showed the following:

* Purpose: to provide guidelines for appropriate triage of obstetrical patients presenting to the ED.

* Policy: All obstetrical patients presenting to the ED will be triaged by a licensed member of the nursing staff. The ED physician will provide medical screening to determine whether an emergency medical condition exists.

* Procedures:

- Obstetrical patients presenting to the ED with an estimated gestational age of 20 weeks or greater will be triaged in the ED by the ED triage nurse using a rapid triage assessment form. If the patient's chief complaint is potentially obstetrical related (i.e., abdominal cramping, non-traumatic back pain, vaginal bleeding or pressure) the patient will be transported to Hospital B or tertiary center.

- All patients in the active labor will be evaluated by an ED physician and a transfer to Hospital B or tertiary center if indicated.

- All patients with impending delivery will be evaluated by the ED physician.

On 2/22/23 at 1021 hours, an interview was conducted with the CNO about perinatal services that would be provided to the ED patient. The CNO stated the hospital had currently contracted with Hospital B to provide the maternal and neonatal services. Hospital B is to provide RNs transport team for mothers and babies and provide education to the hospital staff. The CNO stated Hospital B provided to the hospital staff the education and training related to the Maternal -Fetal Emergencies in 2021. The CNO stated the hospital had adopted those educational materials and Hospital B's Obstetrical Patient Triage Algorithm as the hospital's protocol.

Review of the [Hospital Name] Obstetrical Patient Triage Algorithm showed the following:

* For patient with more than 20 weeks EGA and imminent delivery, call Hospital B Maternal Transport Team, request NICU transport team activation, stabilize the patient, start IV, draw labs, request the OB/GYN advise for treatment plan, and set up for delivery. Maternal and neonatal teams will assist staff with care of the patients, documentation, and transport when stable after delivery.

* For patient with more than 20 weeks EGA/antepartum/intrapartum/and post-partum condition or emergencies. call Hospital B maternal transport team, request perinatal transport RN, stabilize the patient, start IV, request OB/GYN advise for treatment plan while waiting for transport nurse. For the unstable patients, and patients with greater than 24 weeks EGA, it may require the perinatal RN for transporting the patient.

Review of the Maternal-Fetal Emergencies educational materials dated 5/13/21, showed the OB Triage include to ask the maternal patient for any vaginal bleeding, loss of fluid, uterine contractions, and fetal movement.

Review of Patient 20's medical record was initiated on 2/23/23. Patient 20's medical records showed Patient 20 came to hospital on 2/11/23 at 2327 hours.

Review of the Triage Report electronically signed by RN 2 on 2/11/23 at 2341 hours, showed the following:

* Patient 20 was triaged on 2/11/23 at 2339 hours.

* The Patient Narrative section showed Patient 20 claimed she was eight months pregnant and had no prenatal care. The patient had lower abdominal pain associated with vomiting. The patient denied vaginal bleeding. The patient stated the patient was having withdrawal from fentanyl (a narcotic, pain medication) and the last use of fentanyl was "yesterday" (or on 2/10/23).

* The Pain Assessment section showed the pain score/scale/location section was left blank.

* The patient's ESI level was "3."

There was no documented evidence the triage nurse asked Patient 20 for loss of fluid, the length of uterine contractions, and the fetal movement as per the hospital's protocol.

Review of the Progress Notes Report from 2/10/23 at 1436 hours to 2/22/23 at 1436 hours showed the following:

* On 2/12/23 at 0017 hours, RN 2 documented MD 1 performed the pelvic examination for the patient and ordered to call Hospital B for transferring the patient. RN 2 spoke to the charge nurse of Hospital B's L&D unit. Hospital B's OB physician was currently in a procedure and would return the call.

* On 2/12/23 at 0053 hours, RN 2 documented Hospital B accepted Patient 20 as per MD 1. The transport team would arrive to the ED with the ETA of 0130 hours.

* On 2/12/23 at 0401 hours, RN 5 documented at 0124 hours, Patient 20 stated she was pushing and felt the baby coming. RN 5 was at the bedside, saw the baby's head had already come out and immediately followed by the rest of the baby's body. The baby and Patient 20 were transferred to Hospital B by Hospital B's transport team at 0410 hours.

Review of the Emergency Department Record electronically signed by MD 1 on 2/12/23 at 0754 hours, showed Patient 20 was in a premature labor. The case was discussed with Hospital B's physician who agreed to transfer the patient to Hospital B. The patient would be transported with the L&D nurse. The patient was stable for transferring to the high level of care. As the transportation was arranged, the patient precipitously delivered.

On 2/23/23 at 0904 hours, an interview was conducted with RN 2. RN 2 was asked his triaging of Patient 20 on 2/11/23. RN 2 stated the RN triaged the patient with the chief complaint of abdominal pain and contractions. RN 2 did not document the patient's pain level when triaging the patient. RN 2 stated Patient 20 told RN 2 that she was 35 weeks of pregnancy and had no prenatal care. RN 2 stated RN 2 attended Hospital B's training one time. RN 2 stated the RN did not document Patient 2's contraction and baby activity in the triage notes. RN 2 stated RN 10 applied the fetal monitor on the patient, but RN 2 did not know how the fetal monitor worked.

On 2/24/23 at 1035 hours, during an interview with the ED Director, the ED Director was asked about Hospital B's contracted service and the ED OB triage training. The ED Director stated the contract with Hospital B was happened before the ED Director became the ED Director. The ED Director was not aware of the training and competency for OB triage at that time.

On 2/24/23 at 1521 hours, the CNO was asked about the hospital's P&P "Obstetrical Patients, Triage of " showing the triage nurse using a rapid triage assessment form for their OB patients. The CNO stated the hospital did not have that form. The hospital's P&P related to triaging for OB patients was not reflecting the hospital's current practice.


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3. Review of the hospital's P&P titled Competency Assessment and Reporting dated February 2018 showed the following:

* Purpose: To ensure that each employee of the hospital is competent in the knowledge and skills required to carry out his or her responsibilities throughout employment and to ensure levels of competence and competency maintenance are reported to the Governing Body at least annually.

* Procedure:

- Competency Assessment is a mechanism whereby all manager verify their employees' understanding and performance of skills for safe and competent practice in their area of responsibility.

- Competency assessment is decentralized to the unit or department level.

- Age specific competencies are required for designated positions. The special needs and behaviors of specific age groups must be considered in the process of competency definition.

* Through an ongoing and systematic pre-employment process, the Human Resources Department will ensure all staff positions throughout the company have current job description and defined qualifications and will identify New Employee Orientation competency requirements and coordinate the New Employee Orientation program.

* Annually, managers will review competency requirements for each job classification within his/her departments and will assess the relevance of the competency requirements to the organization's mission, vision, and goals. Minimum competency requirements must address safety, fire, disaster preparedness, infection control, and the department specific P&P. Managers will validate all employee' competencies annually at regular defined intervals; if competencies are not met, describe in writing, an action plan indicating how and when the requirements will be met. Managers will validate the competence of the new employees within the Initial Performance Review period; if competencies are not met, describe in writing, an action plan indicating how and when the requirements will be met. Managers will maintain competency documentation for reporting and tracking requirements. Managers are responsible for developing and maintaining current job descriptions for each job classification (includes functions performed by contracted personnel).

Review of the hospital's P&P titled Initial and Annually Required Competencies dated February 2018 showed in part:

* Policy: The company will ensure its employees are competent at the time of hire and maintain acceptable levels of competency throughout employment for the safe and effective performance of assigned duties. Fulfillment of these requirements will be met through initial and ongoing education in the following areas:

- Abuse Policy Education

- Emergency Preparedness

- Fire Prevention/Life Safety Management

- Infection Prevention

* Procedure: Requirements will be met by new employees during pre-placement and New Employee Orientation. Topics will be reviewed annually thereafter and updated accordingly. It is the responsibility of all department heads to ensure all staff completes the annual required in-services.

* Responsibility: The Manager will review test results and, if necessary, verify employee understanding.
a. Review of the Job Description/Evaluation Form for the ED RN showed one of the requirements for the ED RN position is to have a minimum work experience of two years acute care or related experience preferred, Behavioral Health experience preferred.

On 2/22/23 at 1057 hours, an interview was conducted with RN 8. RN 8 was asked about the work experience she had as an RN. RN 8 stated she started working with the hospital ED three months ago. She was an ED nurse at another hospital for six months. She recently passed the board examination and became a RN in March 2022.

On 2/24/23 at 0725 hours, an interview was conducted with RN 5. RN 5 stated he was a newly graduated RN but completed the ED New Grad 6 months training program.

On 2/27/23 at 1445 hours, an interview and concurrent review of personnel files for RNs 5 and 8 was conducted with the Human Resource Manager.

* Review of RN 5's personnel file showed RN 5 was initially licensed as an RN on 3/23/22 and was hired at the hospital as an ED RN on 4/18/22. RN 5 had less than one month experience of being an RN when hired as the ED RN on 4/18/23.

* Review of RN 8's personnel file showed RN 8 was initially licensed as an RN on 2/28/22 and was hired at the hospital as an ED RN on 11/14/22. RN 8 has less than nine months experience of being an RN when hired as the ED RN on 4/18/23.
On 2/27/22 at 1645 hours, an interview was conducted with the CNO and ED Director. The CNO and ED Director was asked about the minimum experience requirement for the ED RN of two years as shown on the Job Description/Evaluation Form dated 8/22. The CNO stated the hospital's practice was to hire the newly graduated RN and put them in the ED training program; however, the job's minimum experience requirement of two years and Behavioral Health experience preferred had not been changed on the Job Description requirement. The CNO stated recently she sent over to the Human Resource the new minimum experience requirement that the behavioral health experience and two years of acute care experience were removed. The CNO was asked when the new minimum experience requirement was officially effective. The CNO stated the Human Resource approved to use the new Job Description or Evaluation without the two-year minimum experience requirement of the acute care or related experience which was first used on 2/20/23. However, RNs 5 and 8 were newly graduated RNs who did not meet the qualification of the ED RN staff at the time of hiring (on 4/18/22 and 11/14/22).

On 2/28/23 at 1300 hours, an interview and concurrent record review was conducted with the ED Director. The ED Director was asked about RN 8's self-evaluations as proficient or expert on Initial Competency Validations in the ED Nursing Orientation Checklist, restraints, EKG, Arctic Sun, IV Admixture Preparation, Moderate Sedation, and Assisting with Splints Application; and the Validator's Assessment showed RN 8 was proficient. The ED Director stated the Initial Self Evaluation and the Validator's Assessment were not correct and she would have to redo the evaluation. The ED Director of ED stated the ED did not have many preceptors; if the new RN's preceptor was off, then the new ED RN would be partnered with another ED RN.

b. On 2/27/23 at 1645 hour, an interview and concurrent record review was conducted with the ED Director and the CNO. The ED Director and CNO was asked about the ED RN Triage training, who would be trained, and what training the hospital provided to the ED RNs. The CNO stated the seasoned or the ED RNs with years of experienced were the ones who were assigned to be the Triage RN and would take the triage test. All ED RNs were to take the online Triage Training.

However, the Triage Competency of RNs 1, 2, and 11 did not show the tests were checked to determine if the answers were correct.

The CNO showed the ED Triage ESI Level Interrater Reliability Verification Forms dated 1/13 and 11/26/22, where the assigned ED Triage RNs validated themselves on how to triage the ED patients. The form showed there would be two ED staff assigned to triage for one patient. However, the "DATES ESI PERFOMED" by two ED staff were different for each patient. The CNO was asked about the accuracy of the validations when it occurred on different dates. The CNO stated she did not realize the validation performed on different dates.

On 2/28/23 at 1315 hours, the ED Director was asked about the list of Triage Online Training of the ED RNs showing the training was done for the year of 2021. The ED Director stated the Online Triage Training was required yearly for all ED RNs, but the hospital educator did not know the online Triage Training was required yearly for the ED RNs.

c. On 2/24/23 at 1230 hours, an interview and concurrent review of RN 4's personnel files was conducted with the Human Resource Manager.

Review of RN 4's personnel file showed RN 4 was employed at the hospital since 2008 and was transferred to the ED on 1/13/09. RN 4 had not completed any training for the Fire and Safety since the RN was first employed. RN 4 had not completed competency/training on Infection Control since 8/1/08. RN 4 had not completed competency on the Abuse Reporting since 8/1/08. There was no documented evidence to show RN 4 had completed the EMTALA training in 2021 and 2022.

When asked if the Fire and Safety training was offered to employees during their hiring or orientation, the Human Resource Manager stated she was told they don't have to do it. When asked about other annual required training, the Human Resource Manager stated the ED Director would most likely have them.

d. On 2/24/23 at 1230 hours, an interview and concurrent review of MHW 1's personnel files were conducted with the Human Resource Manager.

Review of MHW 1's personnel file showed MHW 1's date of hire was 11/10/22. There was no documented evidence showing MHW 1 had completed the EMTALA and Fire and Safety training. When asked about the EMTALA training for the MHW, the Human Resource Manager stated it was not in the file and would most likely be with the ED Direct

Based on interview and record review, the hospital failed to ensure the necessary stabilizing treatment within the capabilities of the hospital for eight of 21 sampled patients (Patients 4, 5, 7, 8, 11, 17, 20, and 21) as evidenced by:

1. The ED staff did not implement the hospital's P&P and protocols related to assessment for the post-partum patient (Patient 20) and newborn (Patient 21) when Patient 20 delivered Patient 21 in the ED. In addition, the hospital's protocol related to the maternal and fetal emergencies was not consistently provided to the ED staff who would provide care to patients receiving the ermergency delivery in the ED.

2. The hospital did not ensure the neonatal, pediatric, and adult crash carts were maintained as per the hospital's P&P for the patient use in the emergent event.

3. The ED staff did not ensure pain management for Patients 17 as per the hospital's P&P.

4. Patient 7 was born in the ED and was assessed for APGAR scores in one and five minutes after delivery. There was no documented evidence showing the ED staff performed further assessment for Patient 7 or provided care to the patient while waiting for the transfer to Hospital B.

5. The ED staff did not assess the vital signs every two hours for Patients 4 and 8 as per the hospital's P&P.

6. The ED staff did not complete the Safety Checklist forms for Patients 5 and 11 as per the hospital's P&P.

These failures had the potential to result in poor health outcomes and serious adverse events to the patients receiving the ED services.

Findings:

1. On 2/22/23 at 1021 hours, an interview was conducted with the CNO about perinatal services provided to the ED patients. The CNO stated the hospital had suspended their perinatal services in 2021. The CNO stated the hospital had currently contracted with Hospital B to provide the maternal and neonatal services. Hospital B was to provide th RN transport team for mothers and babies and provide education to the hospital staff. The CNO stated Hospital B provided the education and training which was the Maternal-Fetal Emergencies to the hospital staff in 2021. The CNO stated the hospital had adopted those educational materials and Hospital B's Obstetrical Patient Triage Algorithm as the hospital's protocol. The CNO stated there was the binder contained the contracted service with Hospital B, had been kept in the ED as their reference. The CNO stated the hospital should follow the protocol to transfer the maternal patients with more than 20 weeks GA to Hospital B unless the delivery would be occurred immediately. The hospital used the Maternal /Newborn Data Sheet to record the OB delivery. The CNO stated the hospital did not use the fetal monitor on the maternal patients to monitor the fetal activities.

Review of the hospital's P&P titled Delivery, Emergency (Childbirth) dated July 2021 showed in part:

* Purpose: to assist with care of emergency childbirth for patients arriving in the Emergency Department before transport to the receiving facility.

* Policy:

- Patients in labor who are not in imminent threat of delivery are to be transferred to [name of the hospital] or tertiary center.

- All pregnant patients in imminent threat of delivery will be immediately examined by the ED physician.

- If the patient is unstable for transport, the patient will remain in the ED and the ED physician will deliver the baby.

- The ED staff will call the [name of the hospital] maternal and neonatal transport team.

- The ED will set up for delivery and gather all supplies.

a. Review of the Maternal- Fetal Emergencies educational materials dated 5/13/21, showed the postpartum assessments include the vital signs (temperature, BP, HR, RR, oxygen saturation, and pain), lochia (the amount, color, consistency, quantitative by weighing pads), fundal massage, and pericare (change pads as needed). Further review showed to document every 15 minutes the postpartum assessments.

Review of Patient 20's medical record was initiated on 2/23/23. Patient 20's medical records showed the patient came to hospital ED on 2/11/23 at 2327 hours.

Review of the Triage Report electronically signed by RN 2 on 2/11/23 at 2341 hours, showed Patient 20 claimed she was eight months pregnant and had no prenatal care. The patient had lower abdominal pain associated with vomiting. The patient denied vaginal bleeding. The patient stated the patient was having withdrawal from fentanyl (a narcotic, pain medication) and the last use of fentanyl was "yesterday" (or on 2/10/23).

Review of the Progress Notes Report dated 2/12/23 at 0401 hours and documented by RN 5, showed Patient 20 came to the ED with the chief complaint of lower abdominal pain with the pain level of 10 out of 10 (on the pain scale from zero to 10, zero means no pain and 10 means the worst pain). The patient was taken to Bed 2 where the patient received pain medication and was examined. The patient was having contractions averaging 30 seconds in length and 90 seconds between the contractions. At 0124 hours, Patient 20 stated the patient was pushing and felt the baby coming. RN 5 was at the bedside. The baby's head had already come out and immediately followed by the rest of the baby body. The baby was pink and had a strong cry. The patient and baby were stable. The baby and patient were both transferred to Hospital B by the Hospital B transport team at 0410 hours.

Review of the Emergency Department Record electronically signed by MD 1 on 2/12/23 at 0745 hours, showed Patient 20 was 35 weeks of pregnancy and was self-detoxing from meth (methamphetamines, a highly addictive stimulant) and fentanyl. The patient presented to the ED with contractions. The patient's FHR was 137 bpm. The patient was in a premature labor. The patient would be transferred to Hospital B with the L&D nurses. Patient 20's contractions were continued and the patient was given 4 mg morphine (a narcotic pain medication) and Zofran (medication used to prevent or treat nausea and vomiting). As the transportation was arranged, the patient was precipitously delivered. The patient's vital signs remained stable. The placenta was delivered. The patient was then placed on a Pitocin (a medication used to induce labor, strengthen the uterine contraction, or to control bleeding after childbirth) drip. Patient 20 was given a liter of NS (normal saline) IV fluid. The patient then became hypertensive. The patient was given MG (magnesium) sulfate (a medication used to reduce the risk of eclampsia in patient with postpartum preeclampsia) and Procardia (a medication used to treat high blood pressure) with the improvement of the BP. The patient was not transported to Hospital B until the BP was controlled.

Review of the MAR showed on 2/12/23, Patient 20 received Zofran 4 mg IV at 0107 hours, morphine 4 mg IV at 0107 hours, nitroglycerin (a medication used to treat or prevent chest pain or pressure) 0.4 mg sublingual at 0159 and 0203 hours, magnesium sulfate 2 gram IVPB at 0217 hours, nifedipine (or Procardia) 10 mg capsule at 0254 hours, and acetaminophen (medication used to treat pain or fever) 650 mg at 0338 hours.

Review of the Vital Sign Report showed on 2/12/23 after the delivery, Patient 20's vital signs were not completely assessed as follows:

- At 0201 hours, the patient's BP was 204/89 mmHg. The temperature and pain score sections were blank.

- At 0207 hours, the patient's BP was 192/93 mmHg. The temperature and pain score sections were blank.

- At 0227 hours, the patient's BP was 170/79 mmHg. The temperature and pain score sections were blank.

- At 0234 hours, the patient's BP was 155/82 mmHg. The temperature and pain score sections were blank.

- At 0237 hours, the patient's BP was 155/82 mmHg. The temperature and pain score sections were blank.

- At 0254 hours, the patient's BP was 178/86 mmHg. The temperature and pain score sections were blank.

- At 0300 hours, the patient's pain level was 10 out of 10. The temperature section was left blank.

- At 0311 hours, the patient's BP was 147/77 mmHg. There was no temperature or pain level documented.

- At 0326 hours, the patient's BP was 132/75 mmHg. There was no temperature or pain level documented.

There was no documented evidence showing Patient 20's vital signs including temperature, BP, and pain score was assessed at the time of transferring the patient to Hospital B.

There was no documented evidence showing the ED nursing staff assessed Patient 20 for lochia, provided fundal massage, or provided pericare to the patient as per the hospital's protocol.

b. Review of the Maternal- Fetal Emergencies educational materials dated 5/13/21, showed the Immediate Newborn Assessment includes to dry and stimulate the newborn by using warmed blanket, to check ABC (airway, breathing, circulation), to assess APGAR scores, to examine briefly to detect any congenital malformation, and document every 15 minutes.

Review of the Maternal/Newborn Data Sheet showed the Newborn Information section include the newborn's sex, APGAR score, the question if the baby breathed before cord was clamped, DCC, cord milking, weight, and length. The APGAR assessment is to be done in one and five minutes.

Patient 21 's medical record was reviewed with RN 2 on 2/23/23 at 0914 hours and the CNO on 2/24/23 at 1521 hours.

Review of the Triage Report electronically signed by RN 2 on 2/12/23 at 0151 hours, showed Patient 21 was triaged on 2/12/23 at 0144 hours. The patient's ESI level was "1." The patient was a newborn with imminent delivery at 0124 hours and had the APGAR of 8. The patient's oxygen saturation level was 80%.

Review of the Progress Notes Report showed the following:

* On 2/12/23 at 0124 hours, Patient 21 was vaginal delivery. The APGAR score was eight. The patient was having pinkish color, crying with good sound, placed in the incubator to warm the patient up. At 0130 hours, Hospital B accepted the patient. The patient was waiting to be transferred to Hospital B.

* On 2/12/23 at 0151 hours, Patient 21 was in the baby warmer and crying with good sound. The patient's oxygen saturation was 92% with two liters if oxygen via nasal cannula. The patient's HR was 140s bpm. The patient's skin was pink. The patient remained to transport to Hospital B.

* On 2/12/23 at 0245 hours, Hospital B NICU team came to pick up the patient. The patient was in a stable condition.

Review of the Vital Signs section of the ED summary Report showed on 2/12/23, Patient 21 was assessed for vital signs as follows:

- At 0144 hours, Patient 21 was assessed for temperature, pulse, respiratory rare, and oxygen saturation level. However, there was no BP documented.

- At 0151 hours, the patient was assessed for temperature and BP. However, there was no respiratory rate documented.

- At 0204 hours, the patient was assessed for pulse, respiratory rate, oxygen saturation level, and oxygen delivery. However, there was no temperature and BP documented.

- At 0246 hours, the patient was assessed for pulse, respiratory rate, and oxygen saturation level. However, there was no temperature and BP documented.

Further review of Patient 21's medical record showed there was no documented evidence the Maternal/Newborn Data Sheet was completed and Patient 21 was assessed as per the hospital's protocol.

Review of the Emergency Department Record (Pediatric) electronically signed by MD 1 on 2/12/23 at 1910 hours, showed Patient 21's APGAR score was nine at one minute and 10 at five minutes. However, the patient's oxygen saturation level was 70% on the room air at one minute and 85% with two liters of oxygen via nasal cannula at five minutes. The patient's oxygen saturation level subsequently increased to 95%. Patient 21 was placed in a warmer and monitored. Hospital B was contacted and discussed the case. The patient was subsequently transferred to Hospital B NICU.

On 2/23/23 at 0904 hours, an interview was conducted with RN 2. RN 2 stated he had been trained with Hospital B training related to the maternal-fetal emergency. RN 2 stated RN 2 checked Patient 21's color and breathing; and had MD 1 double checked the patient. RN 2 stated Patient 21 stayed in the Panda Warmer (a radiant heating source to keep the newly delivered infant warm and safe) until the patient was transferred to Hospital B NICU. RN 2 stated RN 2 had no knowledge of the hospital's P&P or protocol related to monitoring a newborn. RN2 stated he did the best he could for the patient. RN 2 stated the delivery was infrequently happened in the ED.

On 2/24/23 at 0725 hours, an interview was conducted with RN 5. RN 5 was asked about the care provided to Patient 20 on 2/12/23. RN 5 was aware of Patient 20 had pain with the pain level of 10 out of 10. RN 5 was at the patient's bedside and reassessed the patient every 10 to 15 minutes. RN 5 stated he delivered the baby. RN 5 stated he told the patient not to push. RN 5 stated there was a fetal monitor applied on the patient but did not recall who and when it was applied on the patient. RN 5 could not recall who was watching or monitoring the fetal monitor. RN 5 stated RN 5 did not know how to monitor the fetal heart rate. RN 5 stated at 0124 hours, Patient 20 told RN 5 that the baby was out. RN 5 stated RN 5 immediately wore gloves, held the baby's head, and supported the baby's neck. RN 5 stated shortly, the whole baby body came out. RN 5 stated there was no other ED staff at the bedside and RN 5 sounded for help. RN 5 stated MD 1 went to the bedside along with other ED staff. When asked what happened after the baby came out and how the placenta was delivered, RN 5 stated he stayed with the patient, took BP, and did not know how MD 1 clamped and cut the umbilical cord, or delivered the placenta. RN 5 stated he took Patient 20's vital signs after the delivery and gave the data to RN 2 or the charge nurse. RN 5 stated RN 2 told RN 5 that RN 2 would take care of it. However, RN 5 could not locate the document of the completed vital signs in Patient 20's medical record. RN 5 stated RN 5 knew there were RNs came from Hospital B after Patient 20 delivered. RN 5 did not know when or who arrived. RN 5 stated RN 5 was not aware of the OB contracted services with Hospital B. RN 5 stated he had not received Hospital B maternal-fetal emergencies training and had no knowledge that the ED had a blinder contained the OB contracted service with Hospital B or the OB transfer algorism. RN 5 stated he learned the OB delivery from his nursing school, but RN 5 had not seen a delivery before. RN 5 was not sure the ED maternal and fetal care competency was one of the ED requirements. RN 5 stated for Patient 20's post-partum care, RN 5 was checking the patient's vital signs and patient comfort which had no difference with other ED patients.

On 2/28/23 at 0736 hours, an interview was conducted with MD 1. MD 1 stated Patient 20 came to the ED on 2/11/23 about midnight. MD 1 stated he was continually treating other patients who had already been in the ED. MD 1 stated the ED staff continually monitored the patient. MD 1 stated MD 1 assessed Patient 20 who was a 35-week gestation, had the contractions, had no abdominal tension, and had the intact membrane. MD 1 stated MD 1 was aware this was a precipitous labor. MD 1 contacted Hospital B's L&D for transfer, but Hospital B team was scheduled to come at 0130 hours. MD 1 stated MD 1 was providing care to another patient and heard a baby crying and ED staff was calling him. MD 1 stated Patient 20 delivered herself. MD 1 stated the baby (Patient 21) was completely delivered when MD 1 came to the bedside. MD 1 stated MD 1 was looking for clamps to cut the umbilical cord, but the opened delivery pack only had one clamp instead of two clamps. MD 1 stated the ED staff had to look for the second delivery pack and it was delay in couple minutes delay. MD 1 stated once the umbilical cord was cut, MD 1 delivered the placenta. MD 1 stated it had been noticed that the newborn baby had some peripheral cyanosis and the baby's oxygen saturation level was 70%; it might be caused by the cleaning of a newborn was not completed. The oxygen was adminstered to the baby and the baby's oxygen saturation level improved. MD 1 confirmed the ED staff used the fetal monitor on this patient; it was a portable device. It took Hospital B L&D team 35 minutes to come; but the baby was delivered before Hospital B L&D team arrived. MD 1 stated MD 1 communicated with Hospital B NICU team and transferred the baby to Hospital B NICU one hour after the delivery. MD 1 stated the ED immediate delivery had been happened infrequently. MD 1 stated the ED staff were not familiar with the situation.

On 2/28/23 at 1026 hours, an interview was conducted with RN 7. RN 7 stated she worked in the ED for more than a year and did not receive the maternal-fetal emergencies training. RN 7 did not have experience with OB delivery services. RN 7 stated after the baby was born, she helped RN 5 to cleanse the gurney, put OB pads on for the patient. RN 7 stated she did not assess the patient for bleeding, uteral massage, or pain. RN 7 stated Hospital B team was there for Patient 20 before transferring the patient.

On 2/28/23 at 1230 hours, during an interview with the ED Director, the ED Director was asked about staff competency of maternal-fetal emergencies. The ED Director stated she was a charge nurse when the Hospital B program initiated. The ED Director was not sure if all the ED staff had educated from Hospital B team about the transferring and maternal-fetal emergencies. The ED Director stated the ED staff turnover rate was high that made difficult for providing the training to all ED staff. The ED Director stated the competency list for the ED specific tasks was currently developing.


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2. Review of the hospital's P&P titled Crash Cart- Inspection, Availability, Maintenance, & Exchange dated January 2021 showed the following:

- The integrity of the crash cart seals or locks, the functionality of the defibrillator and the availability of the external items shall be monitored daily by nursing unit or ancillary department as evidenced by the documentation of the crash cart daily. The verification of cart supplies and defibrillator check can be done by any licensed or unlicensed staff person that has been verified competent to complete the cart check.

- Central Processing Department (CPD) shall be responsible for maintaining the overall cleanliness of the crash carts. Crash carts shall be cleaned monthly and during the restocking by CPD.

* Crash cart checks daily and monthly:

- During the daily check of the crash cart, nursing unit or ancillary department staff will check only the external items to ensure availability and in-dating. Document the check on the Crash Cart External Contents Daily Check Log. A check indicates that items are present in listed par level, and that the functional test have been performed and passed if indicated. The defibrillator testing joules should be indicated if appropriate.

- Testing the defibrillator: follow the manufacturer's guidelines regarding testing the defibrillator. Zoll R Series defibrillator gives two readiness testing options. The R series defibrillator performs Code Readiness test automatically to verify its integrity and readiness for emergency use. During daily crash cart check, ensure the green check mark at the front panel is on, otherwise proceed to do a manual check.

- The completion of the monthly check should be documented in the appropriate area of the Crash Cart Contents List by CPD.

* After the conclusion of the code blue, nursing unit or ancillary department would call or page CPD to request a crash cart exchange. CPD will respond by replacing the used crash cart immediately with one the two fully stocked crash carts that are stationed in the CPD clean room. CPD exchanges the pediatric, adult, and neonate crash carts. The expiration date of cart items that expire is to be listed in the expiration column. Cart items known to expire have an asterisk.

a. Review of the hospital's P&P titled Equipment; Neonate Care in the ED dated July 2021 showed the following:

* Purpose: to ensure appropriate equipment is readily available for all neonate emergencies in the ED.

* Policy: There will be Neonate Emergency Equipment or supplies available in the hospital at all times to initiate neonatal resuscitation.

* Procedure:

- ED will be checked for adequate supplies daily and at the end of each delivery or use.

- The designee on each day is responsible for assigning which nurse(s) will be responsible for checking the supplies and equipment on that day.

- Respiratory Therapy will be responsible to check the intubation trays.

On 2/23/22 at 1145 hours, an observation and concurrent interview was conducted with the ED Director in the ED. The ED Director was asked for the neonatal crash cart. The ED Director stated the neonatal crash cart was brought down to the Central Supply Department to check and restock the supplies. The ED Director was asked when the neonatal crash cart would be sent back to the ED. The ED Director stated she tried to call the Central Supply Department and could not get anyone to answer, she did not know when it would be sent back to the ED.

On 2/23/23 at 1254 hours, an interview was conducted with the Manager of Materials Department and ED Director. The Manager of Materials Department was asked about the neonatal crash cart. The Manager of Materials Department stated the neonatal crash cart was still in the Central Supply Department getting checked and updated. The Manager of Materials Department was asked how the crash cart contents were tracked. The Manager of Materials Department stated they had not tracked the contents since the OB/L&D unit was closed on 7/14/2021. The Manager of Materials Department was asked for the backup crash cart while the crash cart was being checked and updated. The Manager of Materials Department stated there was only one neonatal crash cart and no back up neonatal crash cart available, the central supply would have to get the items from other facilities to stock them.

b. On 2/22/23 at 1326 hours, an observation and concurrent interview was conducted with RN 4 and the Quality RN Data Coordinator. The pediatric cash cart had several drawers. A defibrillator was observed on top of the crash cart. RN 4 was asked to show how to check the defibrillator. RN 4 stated the defibrillator was checked on the night shift and he was not sure why the time printed on the defibrillator paper was different.

Review of the Pediatric Crash Cart External Content Daily Check Log for the month of February 2023, showed to test the defibrillator with paddles only or by defibrillator internal test. However, there was no documented evidence the defibrillator was tested.

On 2/22/23 at 1350 hours, an observation and interview with the Bio Med and the Quality RN Data Coordinator. The Bio Med was asked about the printed date and time on the defibrillator paper of the defibrillator on top of the Pediatric Crash Cart. The Bio Med turned on the defibrillator and the date showed on the defibrillator was 2/23/23 at 0141 hours which were incorrect. The Bio Med was asked to turn on the defibrillator on top of the adult crash cart in the ED. The defibrillator showed the date and time were 2/22/23 0155 hours and another defibrillator at the nursing station showed the date and time were 2/22/23 at 0159 hours. The above findings were verified with the Bio Med and the Quality RN Data Coordinator.

On 2/23/23 at 1430 hours, an interview was conducted with the QA Director. The QA Director stated the ED used the defibrillator R series that would do the check automatically and would show a green check mark. However, the date and time showed on the defibrillator of the pediatric crash cart were incorrect and the time showed on the two defibrillators of the adult crash carts were incorrect. The QA Director was asked if the RN would use the strip record generated on the defibrillator to document in the patient's medical record when the defibrillator was used for the patient. The QA Director stated yes. However, using the strip generated from the defibrillators would result to incorrect documentation for the patient's medical record as the date and time generated on the defibrillators was incorrect.

c. On 2/22/23 at 1326 hours, an interview was conducted with the Quality RN Data Coordinator, RN 4, and the CS Tech. RN 4 and the CS Tech was asked when the crash cart drawers were checked. RN 4 stated the crash cart drawers were checked only when it was opened. The CS Tech replenished what was used and changed the lock. The CS Tech stated when the drawer was used, the ED staff would inform the CS what was used from the drawer and the CS would replace what was used. When asked, the CS Tech stated the ED staff was responsible in checking the drawers when the drawers had not been used for a year or couple of years.

On 2/22/23 at 1345 hours, the Pediatric Crash Cart small child (purple) drawer was checked with RN 4 and Quality RN Data Coordinator. The following items were missed from the drawer:

- One 4 mm tracheal tube
- Two infant pulse oximeter sensor tape
- One 8 French feeding tube

The urinary catheter French 8 and 10 did not have expiration dates on the packaging. However, on the Pediatric Crash Cart Contents list showed an asterisk (known to expire) on these two items.

On 2/23/23 at 1254 hours, an interview was conducted with the Manager of Materials Department and the ED Director. The Manager of Materials Department was asked how the crash cart supplies in the ED was checked and replaced. The Manager of Materials Department stated the RNs would call the Central Supply for what items were used. The RNs were responsible of checking what was used and would call the CS. The CS would replace the used items. The Manager of Materials Department was asked about the asterisk on the Crash Cart Content list. The Manager of Materials Department stated the asterisk on the list needed to be changed. The Manager of Materials Department stated we would change the way we track the code cart supplies and we will replace the whole tray instead of replacing the items that was used.

3. Review of hospital's P&P titled Pain Management, Assessment and Reassessment, Documentation dated March 2021 showed in part:

* Purpose: to assure that patients receive an assessment and management of their pain consistent with a scope of care, treatment, and service provided by the organization in its various care settings.

- Pain is always subjective. Assessment includes pain ratings obtained with a valid pain measurement tool consistent with the patient's development and or cognitive status.

- Pain measurement tool is a reliable, validated tool used to measure clinical pain intensity.

* Policy:

- Patients are screened for pain as part of patient's initial assessment and on an ongoing basis.

- Each patient shall have a right to pain management through assessment, intervention, and reassessment. Each patient has the right to expect his or her report of pain to be accepted, to have the pain assessed and reassessed, to have interventions provided and to achieve and maintain an optimal level of pain relief.

- The patient will receive a combination of pharmacologic and non-pharmacologic agents if indicated.

- The hospital employees shall assess and report the patient's pain across the continuum and intervene, as appropriate. The nurse will assume the role of patient advocate in assisting patients achieve acceptable level of pain management.

* Procedure:

- All patients will be assessed for the presence of pain using the appropriate scale at least once a shift to establish baseline, with new onset of pain or following procedures to cause pain, additional pain assessment and reassessment will be determined based on patient's clinical condition, complaint of pain, and plan of care.

- Pain management will be assessed on initial assessment.

- Pain assessment will include location, radiation, intensity (using appropriate pain scale), quality in the patient's words, aggravating factors, alleviating factors, effects of pain on quality of life, cultural, spiritual or ethnic, belief, etc.

- Pharmacologic and non-pharmacologic (alternative) pain treatment or interventions exist.

- Pain is reassessed with new reports of pain and following procedures or activities that are expected to cause pain.

- Pain is reassessed following medication given for pain, reassessment pain levels at intervals consistent with route of medication administration. The general guidelines for reassessment includes 15 to 30 minutes for IV medication and 45 minutes to one hours for oral/rectal/sublingual medication.

- Reassess following non-pharmacologic interventions for reported benefits, patient preference, and reduction in presumptive pain indicators in non-verbal patients.

- Document pain assessment and reassessment in the patient's medical records, indicate the presence or absence of pain, utilizing the 0 to 10 scale or other appropriate scale.

* Rate the pain on the scale from 0 to 10, 0 means no pain and 10 means the worst. Moderate pain is in the middle, or from four to six. A rating of one to three would be mild pain. A rating of seven or more is severe pain. The goal is to treat pain early before it gets worse.

Review of Patient 17's medical record was initiated on 2/27/23 at 1341 hours. Patient 17's medical record showed the patient came to the ED on 10/2/22 at 1216 hours.

Review of the Triage Report dated 10/2/22, showed Patient 17 arrived at the ED at 1216 hours and was triaged at 1224 hours. Patient 17 complained of mid abdominal pain radiating to the left lower quadrant with nausea and diarrhea for three days. The patient's pain level was 8 out of 10.

Review of the Vital Signs Report showed Patient 17's pain level was eight out of 10 on 10/2/22 at 1224 hours, three out of 10 on 10/2/22 at 1426 hours, and was eight out of 10 on 10/2/22 at 1559 hours.

Review of the Ambulatory Assessment dated 10/2/22 at 1246 hours, did not show the pharmacologic and non-pharmacologic pain management provided when Patient 17 complained of abdominal pain on 10/2/22 at 1224 hours.

Review of the MAR, showed on 10/2/22 at 1559 hours, ketorolac (non-narcotic pain medication) 30 mg/ml IV was administered to Patient 17. There was no documented evidence Patient 17's pain level was reassessed after the pain medication was given to the patient.

Review of the Leaving Hospital Against Medical Advice signed on 10/2/22 at 1900 hours, showed there was no signature of the witness.

On 2/28/23 at 1155 hours, an interview and concurrent review of Patient 17's medical record was conducted with the ED Director. The ED Director verified the findings. The ED Director confirmed there was no pain intervention provided to Patient 17 when patient complained of abdominal pain with the pain level of eight on 10/2/22 at 1224 hours and there was no documented evidence showing the pain reassessment was completed after the pain medication was given to the patient on 10/2/23 at 1559 hours. There was no documented evidence to show the patient's condition and the time when the patient left the ED. There was no documentation the ED physician and the primary MD was notified of Patient 17's AMA.


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4. Review of Patient 7's medical record was initiated on 2/23/23 at 1020 hours. Patient 7's medical record showed Patient 7 was born the ED by Patient 6 on 2/17/23 at 0802 hours.

Review of the Progress Notes Report of Patient 6's medical record showed on 2/17/23 at 0827 hours, a baby (Patient 7) was delivered; the baby was orally suctioned; and was assessed for APGAR score as of "9/9" (nine out of 10 in one and five minutes. At 0913 hours, the Hospital B team arrived to the hospital. Hospital B team transferred the baby (Patient 7) to Hospital B at 1045 hours.

Review of Patient 7's medical record showed the Maternal/Newborn Data Sheet (undated) showing Patient 7's Apgar scores were assessed at one and five minutes. There were no further nurse notes to show the assessment for Patient 7 after the delivery and upon discharge. There were no nurse notes to show who was providing care to Patient 7 while waiting for the transfer to Hospital B.

On 2/23/23 at 1430 hours, during an inte

Based on interview and record review, the hospital failed to ensure the ED staff appropriately transferred five of 21 sampled patients (Patients 3, 7, 18, 20, and 21). The ED staff did not complete the Interhospital Patient Transfer/Acknowledgement forms when transferring Patients 3, 7, 18, 20, and 21 to other hospitals as per the hospital's P&P. These failures had the potential to result in poor clinical outcomes and serious adverse events to the patients receiving ED services.

Findings:

Review of the hospital's P&P titled Transferring Patients, Emergency Service and Care of dated March 2021 showed the following:

* This protocol has been established to prevent inappropriate transfer of patients with emergency medical needs because of the inability to pay and to guarantee that all individuals seen in the ED are appropriately evaluated, treated, and stabilized prior to inquiring about individual's method of payment or insurance status.

* The transferring nurse is responsible for calling report to the receiving Health Care Facility.

* Patient consent for transfer must be obtained. The ED physician is responsible for explaining the risks and benefits and reason for transfers to the patients and or family members.

1. On 2/23/23 at 0815 hours, Patient 3's medical record was reviewed. Patient 3's medical record showed the patient presented to the ED on 12/31/22 at 0917 hours, with suicidal ideation and was transferred to Hospital C on 12/31/22 at 2020 hours.

Review of the Ambulatory Assessment/History Report showed on 12/31/22 at 0935 hours, Patient 3 was alert and oriented to person, place, time, and date.

Review of the Interhospital Patient Transfer/Acknowledgement form showed the following:

* On 12/31/22 at 1631 hours, the physician signed the section of "Physician Certification...NO EMERGENCY MEDICATION CONDITION EXISTS:"

* The patient's signature section showed the RN signed on 12/31/22 at 2000 hours.

On 2/23/23 at 1430 hours, the ED Director was informed and acknowledged the findings.

2. Review of Patient 7's medical record was initiated on 2/23/23 at 0815 hours. Patient 7's medical record showed the patient was born in the ED on 2/17/23 at 0802 hours, and transferred to Hospital B on 2/17/23.

On 2/23/23 at 1430 hours, an interview and concurrent review of Patient 7's medical record was conducted with the ED Director. When asked, the ED Director could not find any documented evidence showing the Interhospital Patient Transfer/Acknowledgement form was completed for Patient 7 when the patient was transferred to Hospital B.


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3. On 2/27/23 at 1020 hours, review of Patient 18's medical record showed the patient came to the ED on 10/9/22 at 1859 hours, and transferred to other hospital on 10/9/22 at 2319 hours.

Review of the Addendum Note dated 10/9/22, showed Patient 18 would be transferred to another hospital for further evaluation and monitoring. The patient's condition was stable.

Review of the Interhospital Patient Transfer/Acknowledgement form signed by the physician on 10/9/22 at 2250 hours, showed the reason for transfer was for higher level of care. Further review of the form showed the Risks, Benefits, and Witness sections were left blank.

On 2/27/23 at 1651 hours, interview and concurrent review of Patient 18's medical record was conducted with the ED Director. The ED Director verified the above findings.


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4. On 2/24/23 at 1215 hours, an interview and concurrent review of medical records for Patients 20 and 21 were conducted with the Core Measure RN.

a. Patient 20's medical record showed Patient 20 came to the ED on 2/11/23 at 2327 hours, delivered a baby in the ED (Patient 21) and was transferred to Hospital B L&D by Hospital B transfer team on 2/12/23 at 0410 hours.

b. Patient 21's medical record showed Patient 21 was transferred to Hospital B NICU by Hospital B NICU transfer team on 2/12/23 0245 hours.

There was no documented evidence showing the Interhospital Patient Transfer/Acknowledgement forms were completed for Patients 20 and 21 when Patients 20 and 21 were transferred to Hospital B.

The Core Measure RN confirmed the findings.