HospitalInspections.org

Based on record review, Policy review and interview, the facility failed to: a) ensure that the nursing staff reassessed triaged patients as per facility Triage Policy in five (5) out of nineteen (19) Emergency Department (ED) Records reviewed (Patients #26, #25, #24, #15 and #14) and b) assign the correct Triage Levels in two (2) out of nineteen (19) ED Medical Records reviewed (Patients #14 and #16).
.
.
Findings:
.
.
a) Record review revealed Patient #26 presented to the ED on 12/29/14 at 5:12PM with complaint of Abdominal Pain. The initial triage was documented at 5:38PM and the patient was triaged as a Level 3. Vital Signs were taken with Pulse 96, Blood Pressure (BP) 149/96 and Pain Level 10.
.
The patient's Medical Record documents the first re-triage call was made at 1:36AM on 12/30/14, seven (7) hours and fifty-eight (58) minutes after the initial triage.
.
Record review revealed Patient #25 presented to the ED on 12/08/14 at 5:03PM with complaint of Back Pain. The initial triage was documented at 5:05PM and the patient was triaged as a Level 3. Vital Signs were taken with Pulse 100, Temperature 98.6F and Pain Level 10.
.
The patient's Medical Record documents the first re-triage call was made at 11:03PM, five (5) hours and fifty-eight (58) minutes after the initial triage.
.
Record review revealed Patient #14 presented to the ED on 12/10/14 at 6:46PM with complaint of Fever. The initial triage was documented at 6:51PM and the patient was triaged as a Level 3. Vital Signs were taken with Pulse 114, Temperature 101.4F and Pain Level 10.
.
The patient's Medical Record documents the Vital Signs were retaken at 12:54AM on 12/11/14, five (5) hours and fifty-three (53) minutes after the initial triage.
.
Similar findings were noted in two (2) additional records reviewed (Patients #15 and
#24).
.
These findings were confirmed on 01/06/14 at 2:00PM during interview with Staff #8.
.
Review of the current facility Triage Policy titled "Emergency Department Administrative Policy" on 01/07/15, revealed "Patients will be re-assessed as per department standard of a minimum of every 4 (four) hours."
.
.
b) Record review revealed Patient #14 presented to the ED on 12/10/14 at 6:46PM with complaints of Fever, Headache, Back and Throat Pain.
.
The patient had a temperature of 101.4F, Heart Rate of 114 and Pain Level 10.
.
The patient was triaged as "Urgent" Level 3.
.
As per the facility guidelines, the patient should have been triaged as "Emergent"
Level 2.
.
Record review revealed Patient #16 presented to the ED on 12/29/14 at 6:40PM with complaint of Chest Pain.
.
Nursing Notes at 6:44PM document "appears to be in moderate distress".
.
The patient's Heart Rate was 116, Respiratory Rate 24 and Pain Level 10. The patient was triaged as "Urgent" Level 3.
.
As per the facility guidelines, the patient should have been triaged as "Emergent"
Level 2.
.
These findings were confirmed on 01/06/14 at 2:00PM during interview with Staff #8.
.
Review of the current facility , Policy titled "Triage Policy: Emergency Severity Index" on 01/07/15, revealed under "Level II Presentation" that staff should "Consider severe pain / distress 8-10 (eight to ten), together with clinical presentation and vitals in the danger zone. Respiratory Rate (>20) and Heart Rate (>100)."
.
.
.

.
Based on observation, record review and interview, the Nursing Staff failed to: a) reconcile medications accurately, b) obtain corrected Orders, and c) escalate the lack of a Physician response, in one (1) of eight (8) admitted Emergency Department (ED) patients (Patient #4).

a) Review of medical record for patient #4 revealed the nursing facility patient presented to the ED via ambulance on 01/05/15 at 3:21PM with Shortness of Breath. The patient had a diagnosis of Dementia and was admitted to Hospital Services at 9:51PM.

On 01/06/15 at 11:15AM Staff #14 was observed attempting to give the patient the oral medication Atenolol 50mg (milligrams) crushed in applesauce. The patient clenched her teeth and the Nurse was unable to administer the medication.

The Nurse stated "She does have a feeding tube". The patient's daughter was present during the attempt and stated "They give her everything in her G-Tube (Percutaneous Endoscopic Gastrostomy (PEG) Tube) at the nursing home".

Review of the ED Medical Record noted that the nursing facility provided a copy of a list of the patient's medication. The nursing facility's medication list documented all of the patient's medications as administered via "Percutaneous Endoscopic Gastrostomy (PEG)" Tube.

Review of the facility's medication reconciliation revealed the medications were incorrectly documented by the Triage Nurse as "by mouth" in the patient's ED Record.

This was confirmed with Staff #8 at the time of the Medical Record review.

b) During the medication administration observation on 01/06/15 at 11:15AM, Staff #11 was unable to administer Patient #4's medication by mouth.

After the patient's daughter stated that she received everything "in her G-Tube", Staff #13, who was present at the time of the administration attempt, stated "Well then go ahead and give them in her G-Tube".

Staff #11 was then observed administering the oral medication via the G-Tube at 11:30AM as directed by her Supervisor.

This was observed in the presence of Staff #8.

Review of the facility's ED Record revealed no order was obtained from the Physician to give the medication via G-Tube prior to the administration.

During interview on 01/06/15 at 11:45AM, Staff #11 stated "I should have gotten an Order before I gave the medication".

Interview with Staff #8 confirmed the same.

c) Review of Patient #4's Medical Record revealed that the patient had Atenolol 50mg, Sinemet 25-100mg and Aspirin 81mg ordered by mouth which was due to be given on 01/06/15 at 3:30AM.

The Medication Administration Record documented all three (3) medications as "Not Given" with the reason as "failed Dysphagia" Swallow Test.

Also noted in the Medication Administration Record was that a 6:00AM dose of Synthroid 150mcg was not administered due to the failed Dysphagia Test.

Further record review revealed the Nursing Notes on 01/06/15 documented at 5:13AM "All meds ordered PO (by mouth), pt fail Dysphagia Test, MD (physician) paged, awaiting call back".

The record lacks documentation that the information regarding the need for a medication route change was reported to the next Nurse.

At 1:45PM on 01/06/15, the Nursing Notes document "call placed out to Dr (physician) to change p.o. Sinemet. Pending call back."

At 3:30PM the Nursing Notes document " ... spoke to Dr in regards to change p.o. medication to Gastric Tube. As per Dr "call Hospitalists to change p.o. Orders."

At 4:30PM the Nursing Notes document "as per hospital Policies Admitting Attending has to change Orders. A call placed out to Dr and awaiting call back".

At 5:16PM the Nursing Notes document "spoke to Dr about changing p.o. medication to Gastric Tube medication. As per Dr "will change Order when he comes to the hospital". Pending MD Orders, management will continue as needed."

Interview on 01/06/15 at 1:30PM with Staff #8 revealed "There is no Policy that says the Hospitalists can't change an Order".

Staff #8 also stated "The Nurses should have notified their Supervisor when the Doctor did not call back in a timely manner".

Review of the Medical Record notes Sinemet Orders were not changed to G-Tube until 5:42PM on 01/06/15, and the "three (3) times a day" medication was not administered until 10:11PM. The patient did not receive the medication for more than twenty-five (25) hours while in the ED.

The Medical Record also documents the Atenolol, Aspirin and Synthroid Orders were not changed to G-Tube until 9:30PM on 01/06/15. No Aspirin and Synthroid were given on 01/06/15 and the patient did not receive her Aspirin or Synthroid until 01/07/15.

Review of the facility's Policy titled "Chain of Command" dated 03/01/12 revealed under Procedure #2 "Staff member is to notify the Nurse Manager, Departmental Supervisor or Designee of the issue or concern."
.

.
Based on record review and interview, the Nursing Staff failed to document the disposition of Emergency Department (ED) patients who left without being seen after triage in four (4) of six (6) Medical Records reviewed (Patients #5, #14, #15 and #16).

Findings:

Medical record review for Patient #5 documents that the patient was brought to the ED on 12/28/14 at 12:38AM via ambulance for a Fever of 102.4F. The patient was triaged as "Urgent" Level 3.

At 2:59AM Nursing Documentation revealed "Vital Signs slightly improved, family stated they may leave due to wait time. ED Charge RN (Registered Nurse) has been aware and will make room for patient ASAP (as soon as possible)."

There is no further documented evidence of the patient's disposition.

During interview with Staff #9 on 01/07/14 at 2:00PM, the staff member stated "I remember him very well, I was trying to get him back to a bed". When asked if he remembered the patient leaving, he replied "Yes, it was around 3:30AM". When asked if the patient stopped by the window and notified the Nurse that he was leaving, he replied "Yes, I guess I should have written a note".

Medical record review for Patient #15 documents that the patient arrived at the ED on 12/29/14 at 11:20AM with complaints of Shortness of Breath, Intermittent Chest Pain and Right Leg Swollen. The record documents that the patient had a past medical history of Blood Clots in her Lung. An EKG (electrocardiogram) at 11:30AM showed Sinus Rhythm. The patient was triaged as "Urgent" Level 3.

At 4:31PM Nursing Documentation revealed "...pain comes and goes, skin color within normal limits for race, skin is warm and dry, respirations are unlabored, informed of status, patient has dry cough".

There is no further documented evidence of the patient's disposition.

Medical record review for Patient #16 documents that the patient arrived at the ED on 12/29/14 at 6:40PM with complaint of Chest Pain. The patient was triaged as "Urgent" Level 3.

An EKG at 6:48PM showed Sinus Tachycardia. At 6:50PM Nursing Documentation revealed "Patient very restless unable to sit still for EKG, reports he can't breathe".

There is no further documented evidence of the patient's disposition.

Medical record review for Patient #14 documents that the patient arrived at the ED on 12/10/14 at 6:46PM with complaint of Fever. The patient's temperature was documented as 101.4F and Pulse as 114. The patient was triaged as "Urgent" Level 3.

At 6:52PM Nursing Documentation revealed "...patient states all symptoms started yesterday".

There is no further documented evidence of the patient's disposition.

During an interview on 01/07/14 at 10:30AM with Staff #8, the staff member stated that "Staff should be documenting what happens to the patient, or that they left or they couldn't find them".
.

Based on observation, document review, and interview, the facility failed to ensure that all staff comply with Infection Control practices. Specifically a staff member practiced poor hand hygiene and then disregarded instruction to wash hands after patient contact with a patient on Contact Precautions. (Staff #15)

Findings:

The facility failed to ensure that staff providing care to patients requiring Contact Precautions (Patient #9) follow Infection Control practices, specifically handwashing. (See tag A 749)

The staff member placed patients, staff, and visitors at a high likelihood of infection.

.
Based on record review, staff interview and observation, the facility failed to ensure that staff complied with the facility's Infection Control Practices when: a) performing Glucometer Blood Testing (Patients #1, #2, #10 and #11), b) providing care to patients requiring Contact Precautions (Patient #9), and c) visitors are present in rooms designated with Droplet Precautions (Patient #19) to avoid potential sources of cross contamination which increases the risk for the spread of infection.

Findings:

a) On 01/06/15 at 11:37AM on the D Unit, Staff #10 was observed performing Quality Control Testing on the Glucose Meter. When the procedure was completed, Staff #10, at the prompting of the Surveyor, identified that the "High Glucose and Ketone Control Solution" expired 01/02/15, four (4) days prior. The staff member discarded the solution and repeated the test.

During that time Staff #11 confirmed the finding and provided Staff #10 with a new bottle of the control solution.

Review of the Policy titled "Precision Xceed Pro Quality Control Test Procedure" dated 2011, documented "two (2) levels of control (high and low) must be done every 24 (twenty-four) hours when patient testing. Each bottle of control solution is stable for 90 (ninety) days after opening. When a new bottle is first opened, write the current date, the expiration date and your initials on the labels provided and attach to control bottle. Discard all unused solutions 90 (ninety) days after initial opening".

At 11:37AM and 12:00 Noon on the D Unit, Staff #10 was observed performing Blood Glucose Testing on Patient #1 and Patient #2. Staff #10 did not remove their gloves, perform hand hygiene and don gloves between performing the Blood Glucose Testing and cleaning the Glucometer. During both observations Staff #10 had their "dirty gloves" on when they cleaned the Meter.

On 01/07/15 at 11:40AM on SICU (Surgical Intensive Care Unit) Staff #1 was observed performing Blood Glucose Testing on Patient #10 and Patient #11. Staff #1 was observed removing their gloves and donning gloves between performing the Blood Glucose Testing and cleaning the Glucometer. Both observations revealed that Staff #1 did not perform hand hygiene between removing their gloves and donning gloves.

Review of the Policy titled "Hand Hygiene Program" dated 2011, documented to wash your hands after removing gloves.

Review of the Policy titled "Glucometer: Procedure" dated June 2014, documented in Step #3 for the staff member to "gather equipment. Hand hygiene / PPE" (Personnel Protective Equipment) and in Step #15 "to discard any used equipment and wash hands. After each use, disinfect the exterior surface of the Meter with antimicrobial wipe."

On 01/09/15 at 11:25AM during an interview with Staff #12, the staff member agreed that the gloves should have been removed, hand hygiene should have been performed, and gloves should have been donned between performing the Blood Glucose Testing and cleaning the Glucometer. The staff member also stated it is our Policy to perform hand hygiene between the removal of gloves and donning of gloves. The staff member needs to wear gloves when cleaning the monitor due to the use of the wipes to protect the hands. The staff member also agreed that the Policy needs revision to delineate more clearly the procedural steps.

b) Review of Patient #9's Medical Record revealed on 12/23/14 the stool culture was positive for C-Difficile and on 12/14/14 at 8:24AM Contact Isolation was ordered and implemented. The sign outside Patient #9's door revealed that the patient was on Contact Isolation, that you needed a gown and gloves to enter the room, and not to use Purell to perform hand hygiene.

Observation on 01/07/15 at 11:00AM in the SICU, revealed Staff #15 entering Patient #9's room without PPE, gown and gloves. Staff #15 exited the room and used Purell to perform hand hygiene. A Nurse handed Staff #15 a gown which the staff member donned.

Staff #15 entered the room a second time with a gown on but without donning gloves. The staff member went to the patient's bedside and touched the patient's Moss Tube ( a type of feeding tube) without a glove on. Staff #15 then removed their gown, washed their hands with soap and water for approximately five (5) seconds and exited the room.

At the Surveyor's request Staff #2 instructed Staff #15 to wash their hands for the appropriate length of time. Staff #15 washed their hands again with soap and water for approximately five (5) seconds. Once again, at the request of the Surveyor, Staff #2 instructed Staff #15 to wash their hands for the appropriate length of time. Staff #15 put their hands in their pant pockets and walked down the hall.

An interview with Staff #2 at that time revealed that when a patient is on Contact Isolation for C-Difficile, Purell is not effective to perform hand hygiene. The use of soap and water for hand hygiene is required.

Review of the Policy titled "Isolation Precautions Including Standard Precautions" dated July 2014, documented that when a patient is on Contact Precautions (for diarrheal disease) gown and gloves are to be worn before entering the patient's room and removed before exiting the room, followed by hand hygiene. For hand hygiene use soap and water rather than an alcohol hand sanitizer.

Review of the Policy titled "Hand Hygiene Program" dated 2011, documented that when washing your hands with soap and water "rub hands together vigorously for a minimum of 15-20 (fifteen to twenty) seconds, paying particular attention to the tips of the fingers, the thumbs and the area between the fingers".

c) Review of Patient #19's Medical Record revealed on 01/07/15 the patient presented to the Emergency Department with chief complaints of Flu, Urinary Retention and Shortness of Breath after taking Tamiflu. On 01/08/15 at 8:17AM Droplet Isolation was ordered and implemented. The sign outside Patient #19's door revealed the patient was on Droplet Isolation, that you needed a gown, gloves and mask to enter the room.

Observation on 01/08/15 at 11:00AM on the B Unit revealed that two (2) adult female visitors without PPE and an adult male visitor with a mask in Patient #19's room.

During an interview with Staff #16 at that time the staff member stated that visitors receive education regarding PPE and Isolation before entering the Isolation Room however, they refuse to wear the PPE. We can't make them wear the PPE.

At the Surveyor's request the two (2) women and the man were asked to exit the room so they could be interviewed. One (1) of the women stated that they would wear PPE however, none was available and they did not receive education on the PPE. She stated that the male visitor brought his mask from home.

Review of the Policy titled "Isolation Precautions Including Standard Precautions" dated July 2014, documented that when a patient is placed on Droplet Precautions the following PPE is to be worn before entering the patient's room, gloves, gown, (mask and eye shield as required). The "patient and their visitors are educated about the rationale for isolation and their role in preventing transmission in the hospital".
.

.
Based on record review, Policy review and interview, the facility failed to establish a follow-up procedure for triaged patients that left without being seen by a Physician in five (5) out of nineteen (19) ED (Emergency Department) Records reviewed (Patients #14, #15, #24, #25 and #26).

Findings:

Review of the medical record for Patient #26 documents that the patient presented to the ED on 12/29/14 at 5:12PM with complaint of Abdomen Pain. The initial triage was documented at 5:34PM. The patient was triaged as "Urgent" Level 3.

The Medical Record documents discharge at 2:08AM on 12/30/14 as "Not seen by MD/PA (Medical Doctor/Physician Assistant) ". The record lacks documented evidence of follow up with the patient after they left the ED.

Review of the medical record for Patient #15 documents that the patient presented to the ED on 12/29/14 at 11:20AM with complaints of Shortness of Breath with Chest Pain. The initial triage call was documented at 11:33AM. The patient was triaged as "Urgent" Level 3.

The Medical Record documents discharge at 6:12PM on 12/29/14 as "Not seen by MD/PA". The record lacks documented evidence of follow up with the patient after they left the ED.

Review of the medical record for Patient #25 documents that the patient presented to the ED on 12/08/14 at 5:03PM with complaint of Abdominal Pain. The initial triage call was documented at 5:05PM. The patient was triaged as "Urgent" Level 3.

The Medical Record documents discharge at 11:06PM as "Not seen by MD/PA". The record lacks documented evidence of follow up with the patient after they left the ED.

Similar findings were noted in two (2) additional records reviewed (Patients #14 and #24).

An interview on 01/06/14 at 11:00AM with Staff Members #8 and #7 confirmed that the facility lacks a procedure for follow up with patients that leave the Emergency Department after triage without being seen by an MD.

.
Based on record review and interview, the facility failed to ensure: a) a timely Medical Evaluation for Emergency Department (ED) patients after Triage in five (5) out of nineteen (19) ED Medical Records reviewed (Patients #14, #16, #24, #25 and #26), and b) adequate staffing to provide appropriate Nursing care to meet the needs of admitted patients housed in the Emergency Room in two (2) out of eight (8) Medical Records (Patients #20 and #21).
.
Findings:
.
a) Review of the medical record for patient #26 revealed the patient presented to the ED on 12/29/14 at 5:12PM with complaints of Abdomen Pain for two (2) weeks stating she had a CT (computed tomography) scan which showed a Gallbladder Polyp and was directed to the ED by her Physician.
.
The initial triage call was documented at 5:34PM. The patient was triaged as "Urgent" Level 3.
.
The first follow up triage call was documented on 12/30/14 at 1:36AM, eight (8) hours and two (2) minutes after the patient first presented to the facility. Documentation notes the patient "departed" and "Not seen by MD (Physician)/ PA (Physician's Assistant)" at 2:08AM.
.
The Medical Record lacks documentation that the patient received a Medical Evaluation during the eight (8) hour wait from the initial presentation until the first follow up triage call.
.
Review of the medical record for patient #14 presented to the ED on 12/10/14 at 6:46PM with complaints of Fever, Headache, Back and Throat Pain.
.
The initial triage call was documented at 6:51PM. The patient was triaged as "Urgent" Level 3.
.
The first follow up triage call was documented on 12/11/14 at 2:06AM, seven (7) hours and fifteen (15) minutes after the patient first presented to the facility. Documentation notes the patient "departed" and "Not seen by MD/PA" at 2:58AM.
.
The Medical Record lacks documentation that the patient received a Medical Evaluation during the seven (7) hour wait from the initial presentation until the first follow up triage call.
.
Review of the medical record for patient #16 reveals the patient presented to the ED on 12/29/14 at 6:40PM with complaint of Chest Pain.
.
The initial triage call was documented at 6:42PM. Nursing Notes at 6:44PM document "appears to be in moderate distress". The patient's Heart Rate was 116, Respiratory Rate 24 and Pain Level 10. The patient was triaged as "Urgent" Level 3.
.
A Nursing Note at 6:50PM documents "Patient very restless unable to sit still for EKG, reports he can't breathe". An EKG shows the patient in Sinus Tachycardia. No further Nursing Documentation noted in the record.
.
Documentation notes the patient "departed" and "Not seen by MD/PA" at 10:57PM.
.
The Medical Record lacks documentation that the patient received a Medical Evaluation during the four (4) hour wait from the initial presentation until discharge.
.
Review of the medical record for patient #24 reveals the patient presented to the ED on 12/22/14 at 5:39PM with complaints of Fever, Cough and Pleurisy. The initial triage call was documented at 6:30PM. The patient was triaged as "Urgent" Level 3.
.
The first follow up triage call was documented on 12/23/14 at 12:31AM, seven (7) hours and eight (8) minutes after the patient first presented to the facility. Documentation notes the patient "departed" and "Not seen by MD/PA" at 1:22AM.
.
The Medical Record lacks documentation that the patient received a Medical Evaluation from a Physician during the seven (7) hour wait from the initial presentation until the first follow up triage call.
.
Review of the medical record for patient #25 reveals the patient presented to the ED on 12/08/14 at 5:03PM with complaints of Right Back and Abdomen Pain. The initial triage call was documented at 5:05PM. The patient was triaged as "Urgent" Level 3.
.
The first follow up triage call was documented at 11:03PM, six (6) hours after the patient first presented to the facility. Documentation notes the patient "departed" and "Not seen by MD/PA" at 11:06AM.
.
The Medical Record lacks documentation that the patient received a Medical Evaluation during the six (6) hour wait from the initial presentation until the first follow up triage call.
.
b) Review of the medical record for patient #21 reveals the patient presented to the ED via ambulance on 01/07/15 at 3:27PM in Respiratory Distress. The patient was triaged as "Emergent" Level 2, admitted as an inpatient at 7:57PM and was housed in the ED until 11:45PM when the patient was transferred to the Medical Intensive Care Unit (MICU).
.
Review of the Medical Record revealed that an MD Order was placed at 3:52PM, shortly after the patient arrived at the ED for insertion of a Foley catheter and a STAT (immediate) Urinalysis. Documented evidence shows the Foley catheter was not placed until 11:20PM and the Urinalysis was not obtained until 12:30AM on 01/08/15, more than seven (7) hours after the STAT Order was placed.
.
Review of the ED Staff Schedule documents the Nurse's assignment as having two (2) MICU patients, six (6) ED "Treat & Release" patients and two (2) admitted Med-Surg patients during the 7P-7A shift on 01/07/15. The Nurse was assigned ten (10) patients, including the two (2) admitted Critical Care patients.
.
Review of the medical record for patient #20 reveals the patient presented to the ED via ambulance on 12/11/14 at 10:47PM with complaint of Vomiting Blood. The patient was triaged as "Emergent" Level 2, admitted as an inpatient on 12/12/14 at 2:37AM and was housed in the ED until 13:30PM on 12/13/14 when the patient was transferred to the Intensive Care Unit (ICU).
.
Review of the Medical Record revealed STAT MD Orders were placed at 11:58PM on 12/11/14, for a STAT Urinalysis. Documented evidence shows the Urinalysis was not obtained until 7:48AM on 12/13/14, more than thirty-one (31) hours after the STAT Order was placed.
.
Review of ED Staff Schedule documents the Nurse's assignment as having one (1) ICU patient, as well as seven (7) admitted Med-Surg patients throughout the 7P-7A shift on 12/11/14. The Nurse was assigned eight (8) Admitted patients, including the Critical Care patient.
.
On 12/29/14 one (1) Nurse's assignment included fourteen (14) patients, including two (2) MICU patients, four (4) Admitted Med-Surg (Medical-Surgical) patients and eight (8) ED "Treat & Release" patients.
.
On 12/29/14 another Nurse's assignment included six (6) patients, including two (2) MICU patients, four (4) Admitted Med-Surg patients, and three (3) ED "Treat & Release" patients.
.
On 12/16/14 one (1) Nurse's assignment included six (6) patients, including one (1) ICU patient, one (1) Admitted Telemetry patient, three (3) Admitted Med-Surg patients and two (2) ED "Treat & Release" patients.
.
These assignments were confirmed during interview with Staff #8 on 01/09/14 at 1:30PM.