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Based on observation, interview, and record review, the Governing Body failed:

1. To develop, implement and maintain an effective, ongoing data driven quality assessment and performance improvement program for the facility's emergency services, when data was collected since November 2013 (Refer to A 263); and,

2. To ensure emergency services were provided in a safe and effective manner to meet the needs of the patients and the community (Refer to A 1100).

The cumulative effect of these systemic problems resulted in failure of the Governing Body to effectively fulfill it's responsibility to the patients and the community.

Based on record review, the Governing Body failed to ensure the emergency services provided in the facility complied with the requirements of the emergency services Condition of Participation (Refer to A 1100).

Findings:

The "Rules and Regulations of the Governing Board of the Hospital," were reviewed. The purpose of the Governing Board included recommending and implementing Hospital policy, promoting patient safety and performance improvement, and providing quality patient care. According to the "Rules and Regulations," the Governing Board has ultimate responsibility and legal authority for safety and quality of care, treatment and services rendered in the hospital.

A review of the Governing Board Meeting Minutes dated July 18, 2013, was conducted. The following was documented: "Not happy with the progress or lack of progress we need to make in our ER. Many of the findings internally and with the State surveyors..."

Based on interview and record review, the facility failed to develop, implement and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program, by failing to develop, implement, and maintain performance improvement projects in the Emergency Department (ED). This failure led to multiple missed opportunities regarding improving safety and overall patient care in the ED (Refer to A297 and A308).

The cumulative effect of this systemic problem resulted in failure of the Governing Body to ensure the presence of an effective quality program focused on improving the outcomes of patients.

Based on interview and record review, the facility failed to develop, implement and maintain performance improvement projects in the Emergency Department (ED). This failure led to multiple missed opportunities to improve safety and overall patient care in the ED (Refer to A 1100).

Findings:

A group discussion regarding performance improvement plans/projects in the ED was conducted on April 16, 2014, at 11 a.m. The Chief Nursing Officer, the Director and Assistant Director of the Quality Assurance Department, the ED Director, the Directors of the Laboratory and Radiology Departments, the Director of Health information, the Radiology Supervisor, and the facility's National Director of Clinical Operations were present.

A review of the "Hospital Wide Administrative Performance Improvement Plan (Effective 1/7/2013)," was conducted. The purpose indicated, "This Performance Improvement Plan describes the systematic organization wide approach to quality and patient safety that is used to plan, design, measure, assess and improve organizational performance. Under this plan, our organization, provides high quality clinical services and demonstrates the outcomes of services, achieves performance improvement goals in a systematic manner through collaboration with our providers; Provides a culture where care is delivered in a safe environment and quality care is measured, monitored, and continuously improved."

The "Hospital Wide Administrative Performance Improvement Plan," indicated the Governing Body (GB) was responsible for establishing and maintaining the facility's Performance Improvement Plan. According to the plan, the GB was ultimately responsible and accountable for ensuring the ongoing performance improvement program was implemented and maintained.

A concurrent interview was conducted with the Assistant Director of Quality Assurance who stated since November 2013, there had been no performance improvement programs conducted in the ED, as the facility had a change in staff.

The Quality Council and Patient Safety Meeting Minutes for 2014 were reviewed. The minutes failed to show documented performance improvement plans for the ED since November 2013.

Based on interview and record review, the facility's Governing Board failed to ensure an ongoing performance improvement program was implemented for the Emergency Department (ED) since November 2013. This failure can negatively impact safety and the provision of medical care for all patients presenting to the ED (Refer to A 297 and A 1100).

Findings:

A group discussion regarding performance improvements in the ED was conducted on April 16, 2014, at 11 a.m. The Chief Nursing Officer, the Director and Assistant Director of the Quality Assurance Department, the ED Director, the Directors of the Laboratory and Radiology Departments, the Director of Health information, the Radiology Supervisor, and the facility's National Director of Clinical Operations were present.

A review of the facility's Governing Board meeting minutes was conducted on April 16, 2014. Since March 21, 2013, the meeting minutes failed to show documentation of the Governing Boards oversight of the Performance Improvement Program in the ED.

A concurrent interview was conducted with the Assistant Director of Quality Assurance who stated since November 2013, there had been no performance improvement programs conducted in the ED and reported to the Governing Board, as the facility had a change in staff.

A review of the "Hospital Wide Administrative Performance Improvement Plan (Effective 1/7/2013)," was conducted. The "Assignment of Responsibility: Governing Board" indicated, "The Governing board is responsible for establishing and maintaining the (facility's) Performance Improvement (PI) Program. The Governing Board is ultimately responsible and accountable for ensuring: The ongoing performance improvement program is implemented and maintained. The PI program includes patient safety, Setting priorities for data collection and frequency..."

The "Rules and Regulations of the Governing Body," were reviewed. Article VIII, "Governing Board Operation, Section 5. Performance Improvement (PI)," indicated the Governing Board required staff of the hospital department to implement and report on the activities and mechanisms for monitoring and evaluating the quality of patient care, opportunities to improve patient care and for identifying and resolving problems.

Based on observation, interview, and record review, the facility failed to ensure for five ED (emergency department) patients, (Patients 201, 203, 210, 306, and 401) the record included accurate and pertinent documentation to include interventions, care, and treatments. These failures led to records that did not accurately reflect the patient's ED hospitalization, and the potential for an impact on the continuum of emergency medical care.

Findings:

1. The record for Patient 201 was reviewed on April 14, 2014. Patient 201 presented to the ED on April 14, 2014, at 2 a.m., with complaints of "Pain in the chest, unable to breathe."

The nursing document titled "ED Triage" dated April 14, 2014, at 2:11 a.m., indicated "Chief complaint: Pt (patient) c/o (complains of) difficulty breathing, chest pain..."

The document indicated Patient 201's blood pressure was 198/97 (normal 120/80 per American Heart Association- AHA) and a heart rate of 129 ( normal 80 per AHA).

The document further indicated Patient 201's health status was assessed at a level 3 acuity (Urgent -patient's vital signs to be within normal limits).

The document titled "ED Note Physician" dated April 14, 2014, at 2:11 a.m., indicated, "Respiratory symptoms: Shortness of breath...no stridor (a high pitched sound occurring during inspiration a sign of air obstruction), no wheezing."

The document further indicated "General: Pt does state she has throat pain and is currently wheezing and stridor on exam. Respiratory: Lungs are clear to auscultation..."

This was contradictory to the physician's previous note.

The document titled "ED Note Physician" dated April 14, 2014, modified at 11:08 a.m., indicated, "...No hypoxia on O2 saturation (oxygen level)... on my last contact with her...Pt left ED on her own free will after declining tests and treatments..."

The document titled "RT (respiratory therapy) Treatments Form- Text" dated April 14, 2014, at 3:05 a.m., indicated Patient 201 received a breathing treatment and the oxygen level was 90% (normal is 96% per Taber's Cyclopedic Medical Dictionary-a reference used by health care professionals) prior to receiving a breathing treatment.

The document further indicated Patient 201 had "Grunting (an abnormal lung sound heard when breathing is labored).." and labored breathing following the treatment."

Further review of the record indicated Patient 201 had completed tests that included an electrocardiogram (heart tracing), and two X-rays prior to leaving. This was contradictory to the physician's note.

There was no documentation that indicated the last time the physician had contact with Patient 201.

The physicians initial description of the patient was inconsistent in the description of the patient in the physician's initial entry, in the RT documentation, and in the addendum entry by the physician at 11:08 a.m., seven hours and 32 minutes after the patient left without complete treatment.

2. A tour of ED was conducted on April 14, 2014, at 10:05 a.m. Patient 203 was observed dressed in a shirt, pants,and shoes. Patient 203 removed the sheets from the gurney, threw the sheets on the floor, and walked in a rapid pace back and forth.

During an interview with Registered Nurse 3 (RN 3), on April 14, 2014, at 10:20 a.m., RN 3 stated Patient 203 was on a 5150 hold (an involuntary confinement when a person was deemed to be a harm to themselves or others). RN 3 stated a patient admitted on a 5150 hold was assessed for a suicide risk on admission and a safety screening was completed. RN 3 stated the assessment and screening directed the care and treatment and interventions for the patient.

The record for Patient 203 was reviewed on April 14, 2014. Patient 203 presented to the ED on April 14, 2014, at 1:11 a.m., with the chief complaint "very disturb(ed)."

The nursing document titled "ED Triage" dated April 14, 2014, at 1:16 a.m., indicated "Mom states pt has been "acting crazy."

The nursing document titled "Patient Assessment System" dated April 14, 2014, at 3:01 a.m., indicated "Pt admits to homicidal ideation's (thought of wanting to kill) to family members. Suicide precautions initiated."

The document titled "ED Physician" dated April 14, 2014, modified at 6:33 a.m., indicated Patient 203 was on a "5150 psychiatric hold" and had been diagnosed with "Acute bi-polar disorder, acute schizophrenia (mental disorders)."

During an interview with RN 1, on April 14, 2014, at 11:05 a.m., RN 1 reviewed the record for Patient 203 and was unable to find documentation that indicated Patient 203 had a suicide risk screen and safety checklist assessment completed. RN 1 stated "If they were done, they would be here (in the record)."

The facility policy and procedure titled "Nursing Care for Behavioral Health Patient in the ED" undated, indicated "... The Emergency Department Physician..as needed, completes the "Suicide Risk Assessment" to determine the level of care and observation required...If in the course of assessing suicide risk, the patient was identified as "at risk..."

Although there was evidence the patient was homicidal and suicidal, the screenings to determine appropriate care were not completed.

3. The record for Patient 210 was reviewed on April 16, 2014. Patient 210 was a six year old female brought to the ED by her mother, on April 8, 2014, at 12:27 a.m. with complaints of "Asthma".

The document titled "ED Physician" dated April 8, 2014, at 12:37 a.m., indicated "Respiratory distress moderate: Breath sounds: Wheezes present moderate, Retractions: moderate."

The document titled "Final Report" dated April 8, 2014, at 1:14 a.m., indicated "Single view of the chest (X-ray)...Findings concerning for right lower lobe early infiltrate (pneumonia)."

The document titled "Nursing Note" dated April 8, 2014, at 2:55 a.m., indicated "Family did not want to wait any longer and eloped. Pt. has improved and states she is feeling better..."

There was no documentation that indicated Patient 210's respiratory status was assessed prior to leaving the ED. There was no documentation that indicated Patient 210's blood pressure was checked.

There was no documentation Patient 210's mother was informed of the risks of leaving the ED prior to discharge.

During an interview with the Emergency Department Director (EDD), on April 16, 2014, at 11 a.m., the EDD stated it was the facility's practice to inform patient's of the risks of leaving the ED prior to discharge.

The facility's policy and procedure titled "Pediatric Triage Guidelines" undated, indicated "Blood pressure...All children > (greater than) 5 years."



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4. A review of Patient 306's record was conducted. Patient 306 presented to the Emergency Department (ED) on April 14, 2014, at 8:47 p.m.,with a chief complaint of abdominal pain and vomiting. Patient 306 was 12 weeks pregnant. The patient was triaged upon arrival as a level 3, which according to the facility's policy, "Medical Screening & Triage 5 level (Effective 5/28/2009)," indicated the need for emergency treatment was, "urgent."

Patient 306's pain scale (a scale of 1-10 with 10 being the highest level of pain) was reviewed. On April 14, 2014, at 9:04 p.m., the patient's pain scale was at a level 6. On April 14, 2014, at 10:58 p.m., the patient's pain scale was at a level 8, and on April 15, 2014, at 1 a.m., the patient's pain scale was at a level 8.

Further record review reflected a physician's STAT (immediately) order dated April 15, 2014, at 7:21 a.m., for an obstetric ultrasound.

An observation of the ED was conducted on April 15, 2014, at 10 a.m. Ultrasound Technician (UT) 1 was observed in the waiting room calling for Patient 306, with no one responding. An interview was conducted with UT 1 who stated another UT came to the ED at 8 a.m., and again at 8:30 a.m., and was unable to locate Patient 306.

A review of the ED discharge records dated April 15, 2014, at 8:49 a.m., indicated Patient 306's disposition was "LWOT (left without triage)," and the ED disposition was "LWBS (left without being seen."

A review of the Patient Summary Report and the patient's record indicated Patient 306 was triaged on April 14, 2014, at 8:47 p.m. Patient 306 was placed in a bed on April 14, 2014, at 11:47 p.m., and seen by a provider on April 14, 2014, at 11:40 p.m.

After April 15, 2014, at 1 a.m., the record failed to show further nursing documentation to describe the patient's response to care or interventions provided.

The record failed to indicate Patient 306's whereabouts after April 15, 2014, at 1 a.m. when the patient's pain score was documented.

An interview was conducted with the Assistant for Quality Assurance on April 16, 2014, at 2 p.m., who, after reviewing Patient 306's record indicated she was unable to locate nursing documentation describing the patient's status or response to care after April 15, 2014, at 1 a.m.

A review of the facility policy, "Emergency Department Documentation (Effective 8/3/2012)" was conducted. The policy indicated, "An accurate and complete documentation of observations, interventions, and evaluations of care given in the pre hospital phase and within the emergency department is the responsibility of all Nursing Personnel."



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5. The record for Patient 401 was reviewed on February 18, 2014. Patient 401, a 53 year old male, presented (escorted by police) to the ED on December 7, 2013, at 10:21 p.m., with a chief complaint of, "not doing well," and deemed gravely disabled (unable to care for himself).

The triage note, completed at 11:16 p.m., indicated Patient 401 was, "able to stay awake, and trying to answer questions," but was not able to answer the questions, "well." The note indicated the patient's BP (blood pressure) was elevated at 150/95 (normal 120/80), and his heart rate was increased at 103 beats per minute (normal 60-100). The triage nurse identified the active problems with Patient 401 to be head injury, altered mental status, and an autoimmune disease (a disease that attacks the immune system). The triage nurse assigned Patient 401 a level 2 acuity (emergent - a high risk patient who could easily deteriorate [according to the facility policy titled, "Medical Screening and Triage 5-Level]). Patient 401 was placed in an ED bed at 11:33 p.m.

The nursing assessment, completed at 11:45 p.m., indicated the neurological assessment was WDL (within defined limits), meaning there were no abnormalities (not consistent with the initial triage assessment).

Vital Signs were repeated every one to two hours during the remainder of the ED stay, with no repeat assessment of any system, including the neurological system (that was altered on arrival to the ED).

Nurse's notes for the remainder of the ED stay included the following:

a. 1:15 a.m., the patient was given a urinal for urine collection;

b. 2:30 a.m., the patient was asked to please give a urine sample. The patient was sleeping and had not given a sample;

c. 4:55 a.m., the patient was again asked to give a urine sample, no sample was given. The patient refused catheterization to obtain a sample;

d. 7:30 a.m., the patient was sleeping, easily arousable, pending possible admit, no distress was noted, the patient was calm and cooperative, and security was at the bedside; and,

e. the patient tolerated a meal and was resting comfortably.

According to the ED record, a CXR (chest x-ray) was done, urine was collected and tested, and blood was drawn and tested. Review of the blood test results indicated Patient 401 had a BUN (blood urea nitrogen) of 42.2 (elevated), and a creatinine (to analyze the health of the kidneys) of 1.5 (elevated). Both of these results indicated Patient 401 was dehydrated. Further review of the blood test results indicated Patient 401 had a WBC (white blood cell) count of 11.7 (elevated), indicating he had an infection.

The ED record indicated a saline lock (a catheter placed in the vein to be used for medication administration and to administer fluids intravenously) was inserted on December 8, 2013, at 10:16 p.m. (11 hours and 55 minutes after arrival to the ED).

The ED physician's record, dictated December 8, 2013, at 23 minutes after midnight, indicated the following:

a. The physician accepted (agreed with) the triage assessment;

b. Skin symptoms were negative with no breakdown or abrasions. The skin was intact;

c. The head was normal and atraumatic (no signs of trauma);

d. Neurologic symptoms were negative with no altered level of consciousness and no weakness (inconsistent with the triage assessment); and,

e. The patient was cooperative, with an appropriate mood and affect, and normal judgement.

The physician record indicated Patient 401 was evaluated multiple times during his, "extended," stay in the ED, and he remained stable with no changes in the physical examination. The diagnoses were (blood) infection, non-compliance (not following doctor's orders) with home medications, neglected hygiene, and psychiatric hold. The physician record indicated the patient was admitted to the medical surgical floor in stable condition.

The ED record indicated no focus neurological assessments were performed (for 11 hours and 45 minutes) no additional radiology tests were ordered or done, no visual physical assessment/inspection of the patient's head was performed (in the presence of an altered level of consciousness, according to the reason for seeking ED care) no IV fluids were given for hydration, and no medications were given (including for pain or infection) during the patient's stay in the ED.

According to the record, Patient 401 was admitted to the medical surgical floor from the ED on December 8, 2013, at 11:30 a.m. (13 hours and nine minutes after arrival to the ED). The record indicated on admission the patient's neurological status was not WDL, the patient was not oriented to place and time and he had a flat affect.

The nurse's notes indicated Patient 401 was wearing a bandana on his head, and when it was removed to complete a nursing assessment, a large open wound on the top of the patients head extending into the forehead was revealed. The wound was described as red, white, and yellow in color, weeping, edges separated, measuring 10 cm (centimeters) long, nine cm wide, and two cm deep.

Observation of the photo's taken revealed an open, shiny wound on the frontal top area of the head, extending into the forehead. The wound revealed exposed soft tissue, with no evidence of a cranial bone (skull) present.

The record further indicated Patient 401 was experiencing pain at the wound site.

The record indicated the admitting physician ordered a CT (computerized tomography) of the head, pain medications, IV fluids and antibiotics to treat the medical problems Patient 401 was experiencing.

A review of the Head CT indicated the following abnormalities were found:

a. Bony destruction in the frontal area which may reflect advanced aggressive osteomyelitis (infection) or metastatic (spreading of cancer) disease;

b. Soft tissue swelling or mass extending inside and outside the cranium, which may reflect metastatic disease or phlegmon (an area of inflammation that produces pus);

c. Air-fluid level in the right frontal lobe, which may reflect an abcess; and,

d. Extensive edema in both frontal lobes.

The record indicated Patient 401 was started on pain medication, IV fluids, and antibiotics, and eventually transferred to another acute care facility for a higher level of care.

An ammended ED physician report, dictated by the ED physician on December 8, 2013, at 8:16 p.m. (19 hours and 53 minutes after his initial dictation), indicated, "the chart was closed prematurely for admission purposes" (the patient was admitted 11 hours and seven minutes after his initial dictation), and additional information was added. The report indicated during physical examinations and rechecks, the patient was refusing to take the bandana off of his head, and he did not want to be touched. The report indicated the patient became aggressive and pulled the covers over his whole body (not consistent with the initial documentation of the ED physician or the ongoing documentation of the nursing staff).

Based on observation, interview, and record review, the facility failed to ensure 14 of 37 patients in the ED (Emergency Department) were treated in accordance with acceptable standards of practice when:

1. Six patients (Patients 403, 404, 102, 112, 115, and 116) were in the ED on 5150 (psychiatric) holds, and eloped (left without staff knowledge) prior to receiving treatment for their psychiatric condition;

Immediate Jeopardy was called related to this issue of April 17, 2014, and lifted with an acceptable plan of correction on April 21, 2014, at 3:02 p.m.

2. One patient (Patient 401) was dehydrated and had an altered level of consciousness and an extensive head wound, and was not treated for either of these conditions;

3. One patient (Patient 402) presented with hematuria (blood in the urine) and abdominal pain and waited in the lobby for 11 hours without pain medication, monitoring, or examination and treatment by a physician;

4. One pediatric patient (Patient 210) presented with wheezing lung sounds. Patient 210 did not receive medications and laboratory tests as ordered. Patient 210's blood pressure and lung sounds were not monitored;

5. One patient with a history of Diabetes (Patient 201) presented with chest pain and shortness of breath. Patient 201 had a blood pressure of 198/97 and a heart rate on 129 on arrival. Patient 201's blood pressure and heart rate were not reassessed. Patient 201 had an abnormal Electrocardiogram. There was no cardiac laboratory tests ordered;

6. One patient (Patient 110) presented to the ED with vaginal bleeding at 23 weeks gestation (pregnant) and waited in the ED lobby for one hour and 45 minutes prior to being sent to the Labor and Delivery department;

7. One patient (Patient 100) presented to the ED with epigastric pain. Physician orders for STAT (immediate) labs were not followed and the patient eloped prior to the completion of a medical screening exam; and,

8. Two patients who presented to the ED, (Patients 304 and 305), both 19 weeks pregnant, were not given a full obstetric assessment, to include monitoring of fetal heart tones and/or completion of an obstetric ultrasound.

These failed practices resulted in actual (and potential for further) delay in treatment, lack of treatment, and death.

In addition, the facility failed to ensure:

9. A chest x-ray ordered STAT (immediately) for an Emergency Department (ED) patient (Patient 307) was completed in a timely manner (Refer to A1103);

10. Four of seven ED Registered Nurses (RNs) (ED RNs 1, 2, 5, and 6) demonstrated competencies in caring for ED patients prior to being given assignments in the ED (Refer to A1112); and,

11. Nursing staff performed care in accordance with written policies and procedures when;

a. Staff did not follow their policy and procedures regarding nursing care for one patient (Patient 203) admitted to the Emergency Department (ED) under a 5150 hold (when a person is involuntarily confined due to a mental disorder that makes him or her a danger to self and others or is gravely disabled) (Refer to A1112); and,

b. During the triage procedure, the oximeter probe (a devise used to evaluate the oxygen level of patients that is placed on a part of a patient's body such as an ear, finger, or toe) was cleaned between use for four patients (Patient's 211, 212, 213, and 214) (Refer to A1112).

The cumulative effects of these systemic problems resulted in the failure of the facility to ensure the provision of care related to emergency services in a safe and effective manner, and in accordance with standards of practice.

Findings:

1. On April 14, 2014, at 9:30 a.m., a tour of the Emergency Department (ED)was conducted. A security officer was observed sitting at a desk, near the exit of the ED waiting room.

During a concurrent interview, the security officer stated, he was responsible for observing the waiting room. The security officer stated he could be called into the ED if they needed help with 5150 patients (a legal hold -when a person was involuntarily confined due to a mental disorder that makes him or her a danger to self or others or was gravely disabled).

On April 14, 2014, at 10:45 a.m., a security officer was observed standing in the ED near the nursing station, across from a row of beds, numbered 3, 4, 5, and 6. A second security guard was located near the back entrance to the ED.

During a concurrent interview with Security Officer (SO) 3, the SO stated he was watching a 5150 patient in bed 8. The SO stated he was also watching the back door.

On April 14, 2014, at 10:45 a.m., SO 2, was interviewed. SO 2 stated she was watching two 5150 patients, one in bed 3 and one in bed 5. The SO stated the patient in bed 3 was awake, but the one in bed 5 was asleep. SO 2 stated she watched the patients, and if they began to act up, she would ask if they needed anything. The SO stated if the patient got up and attempted to walk out she would let the nurses know. The SO stated she had attended "Crisis Prevention Intervention," classes. According to the SO, the class taught SOs how to de-escalate situations, how to maintain distance, and how to obtain release if the person became physically aggressive with them.

During an interview with ED administrative personnel, on March 14, 2014, at 2:45 p.m., the dispositions (where patients were discharged to) were identified as:

Elopement- Medical screening examination started/done and patient leaves without notifying staff;

Left- patient left prior to being seen by provider; and

AMA-Against Medical Advice- patient left after being seen by provider.

On April 16, 2014, at 12:30 p.m., the employee file for SO 2 was reviewed. SO 2 was an employee of the contracted security agency. SO 2's file contained documentation of her security certification and information about "CPI" training.

During a concurrent interview, Human Resources (HR) staff stated they kept an employee file for the security personnel, but they were trained by the contracted agency. There was no documentation in SO 2's record that indicated she had received information about "sitter duties."

The security officers' training booklet was reviewed. There was no information in the book regarding duties and responsibilities when assigned 5150 patients. The facility quality and personnel staff agreed there was no evidence in the file of training specific to 5150 patients. According to the Interim Director of Continuous Quality Improvement, "security officers are not allowed to touch a patient, they can't lay a hand on them."

During an interview with members of the Quality Council, on April 16, 2014, at 11:30 p.m., the members stated they had identified an increase in the number of 5150 patients that were being seen in the ED, "we had 10 of 12 beds occupied by 5150 patients, on one day." Facility personnel met with other stakeholders (police, ambulance, and mental health providers) to discuss the issue, but no changes were implemented yet.

The Chief Executive Officer (CEO), Chief Nursing Officer (CNO), Emergency Department Director (EDD) and additional administrative staff were notified that Immediate Jeopardy was declared on April 17, 2014, at 1:45 p.m. The Immediate Jeopardy was identified due to the facility's failure to ensure the safety of patients who presented to the facility with psychiatric emergencies, resulting in six patients on 5150 (legal psychiatric hold- where a patient is involuntarily confined due to a mental disorder that makes him or her a danger to self and others or is gravely disabled) eloping from the facility and the potential for injury and death due to the patients' suicidal or homicidal ideations, or grave disability.

During a tour of the ED on April 17, 2014, at 2:30 p.m., a patient was observed with his hands restrained behind his back, being escorted to an ED bed by ED staff, accompanied by two police officers.

During an interview with Security Officer 4 on April 17, 2014, at 2:45 p.m., the officer stated he was monitoring the patient, who was on a 5150 hold. He stated the patient was agitated and threatening to leave, so they called the police to get their assistance. The officer stated security was not allowed to lay hands on patients to restrain them when they were threatening or attempting to leave. He stated security could try to talk the patients into staying, but they could not, "force," them to stay. He stated they called the police to respond to the facility and help them keep the 5150 patients there.

During an interview with Police Officer 1, who responded to accompany the patient, on April 17, 2014, at 3 p.m., the officer stated the hospital called the police all the time to respond to unruly patients. He stated the ED staff would call and ask the officers to put handcuffs on patients who were escalating. The officer stated the staff did not like to put patients in restraints because there was too much paperwork for them to do, so they call for the police to handcuff them (not considered a restraint). The officer stated the police would bring patients in on a 5150, and then get called because the patient eloped, "all the time." He stated the patients were always escaping.

The ED log for March 2014 was reviewed on April 17, 2014. The log indicated during March 2013, there were nine patients who arrived at the facility and had 5150 holds, who eloped before their evaluation and treatment was complete.

a. The record for Patient 403 was reviewed on April 17, 2014. Patient 403, a 27 year old male, presented to the ED (walked in on his own) on March 28, 2014, at 10:26 p.m., with complaints of feeling suicidal (wanting to kill himself).

The triage note, completed at 10:41 p.m., indicated the patient wanted to, "check himself into the hospital before anything happened."

A 5150, dated March 28, 2014, at 11 p.m., written by a facility nurse, indicated Patient 403 was a danger to himself, and was placed on a psychiatric hold (needed to be evaluated by a psychiatrist).

The sitter log (completed by the security person watching the patient to ensure his protection) indicated Patient 403 was placed in the hallway by the ED back entrance. The log indicated Patient 403 was observed by the sitter at 11 p.m., and again at 11:50 p.m. There was no evidence the sitter observed Patient 403 after 11:50 p.m.

The ED nurse's notes indicated Patient 403 eloped at 11:55 p.m. (one hour and 29 minutes after arriving to the ED with suicidal thoughts). There was no evidence the security staff watching him saw him leaving the ED or made any attempts to stop him.

The ED physician record indicated Patient 403 had suicidal thoughts and diagnosed him with schizophrenia, suicidal risk, and depression. The record indicated Patient 403 eloped prior to the completion of the medical screening examination.

b. A second record for Patient 403 indicated he returned to the ED on March 29, 2014, at 7:33 a.m. (seven hours and 38 minutes after he eloped) for a mental health evaluation.

The triage note indicated the patient had been hallucinating since the previous night, and he was suicidal, with a plan for killing himself. The note indicated the nurse identified problems of depression, schizophrenia, and suicidal thoughts.

The ED nurse's notes indicated Patient 403 eloped from the ED at 11:30 a.m. (three hours and 57 minutes after arriving to the ED complaining of suicidal thoughts), while there was a separate medical emergency being tended to by staff. There was no sitter log to indicate the patient was being monitored by security for his safety. There was no evidence the staff who was watching him saw him leaving the ED, or made any attempts to stop him.

The ED physician record indicated Patient 403 presented to the ED with suicidal thoughts for the past two days, and he had a previous history of depression and suicidal behavior. The record indicated a social worker had been called to evaluate the patient for a 5150. According to the record, the patient was aware of the plan, and he eloped before evaluation and treatment could be completed.

c. The record for Patient 404 was reviewed on April 17, 2014. Patient 404, a 29 year old female, presented to the ED (walked in on her own) on March 14, 2014, at 9:27 p.m., requesting to have an, "evaluation."

The triage note, completed at 9:35 p.m., indicated the patient had flight of ideas (a nearly continuous flow of rapid speech that jumps from topic to topic) and was suffering from psychiatric problems.

A 5150, dated March 14, 2014, at 10 p.m., written by a facility nurse, indicated Patient 404 was a danger to herself, and was placed on a psychiatric hold (needed to be evaluated by a psychiatrist).

The ED physician record indicated Patient 404 was having an acute psychotic episode, and was a danger to herself. The record indicated she was medically stable, and needed to be transferred to a psychiatric facility.

The document titled, "Assessment for Level of Nursing Care," was reviewed on April 17, 2014. The document indicated Patient 404 was at risk for assaulting herself or others, and for eloping from the department. According to the document, she was to be monitored every 30 minutes.

The sitter log, completed by the security officers monitoring Patient 404, indicated hourly checks were done from 10 p.m. on March 14 to 2 p.m. on March 15, 2014, with a final monitoring episode entered at 2:26 p.m.

The nurse's notes indicated on March 15, 2014, at 2:58 p.m., the security guard stepped out of the area the patient was in, and the patient eloped. There was no evidence the security officer was monitoring Patient 404 every 30 minutes, that the staff saw her leave, or that any attempts were made to stop her from leaving.

d. The record for Patient 102 was reviewed on April 16, 2014. Patient 102 was a 46 year old female, presented to the ED on March 24, 2014, at 12:32 a.m. According to the registration sign in sheet, Patient 102 indicated her reason for the visit was "Cause damage to myself."

The "ED Screening/History Adult," performed on March 24, 2014, at 12:43 a.m., indicated "Yes" to the following questions:

Suicide Feeling Depressed;
Suicide Feeling Hopeless; and,
Suicide Attempt Last 12 months.

According to documentation, a "Yes answer to any of these three questions puts the patient at risk for suicide and will require further assessment by a physician or a qualified mental health provider to determine the patient's level of risk."

The screening indicated the physician was notified about Patient 102's suicide risk, and the following interventions initiated: "Placement close to nurse station, 1:1, Suicide precautions initiated."

The "Emergency Department Note-Physician," report dated March 24, 2014, performed at 12:59 a.m., indicated the following:

Patient 102 was seen "Immediately upon arrival";

Patient 102 arrived via a private vehicle;

Patient 102 "Per family, patient's demeanor has changed in the last couple of weeks from suicidal to homicidal thoughts, delusion, tried to run off traffic."

The "History of Present Illness," indicated the patient presented with "psychiatric problem, suicidal ideation, depression, anxiety and agitation...The degree of symptoms is severe...eligible for legal hold."

In the section titled "Psychiatric," the physician documented "Not appropriate mood & affect, not normal judgement...Judgement: impaired by abnormal thoughts, Abnormal / Psychotic thoughts: Suicidal."

In the section for disposition "Eloped," was documented

Physician orders included, Ativan (used to treat anxiety) 2 milligrams (mg) every six hours as needed for anxiety, sitter, and transfer to another facility.

The SO "Daily Activity Report," for March 24, 2014, contained the following documentation about Patient 102:

12:55 a.m.- 51-50 in the back hall;
1 a.m.- posted in ER with 51-50 and all code 4 (clear); and
1:08 a.m.-51-50 walked out of ER...[Law Enforcement] was called.

The Daily Activity Report indicated that the SO was "back patrolling parking lot..." at 1:10 a.m. There was no documentation in the report indicating efforts taken by the SO to detain Patient 102.

The facility failed to ensure the safety of Patient 102, who presented to the facility with a psychiatric emergency. Patient 102 was not medically cleared for release and had not had a psychiatric evaluation.

e. The "Abbreviated Emergency Department Log By Date," was reviewed. The log included an entry for Patient 112, that indicated the patient presented to the facility on January 3, 2014, at 2:25 p.m., for medical clearance/5150, and eloped on January 3, 2014, at 4:40 p.m. (two hours and 15 minutes after arrival).

The record fro Patient 112 was reviewed. Patient 112's record contained an "Application for 72 hour Detention for Evaluation and Treatment, (pursuant to Section 5150)" form. The form indicated local law enforcement had placed the hold on January 3, 2014, at 2:13 p.m. because the patient "Tried to hurt his mother...Demons told him to go after his mother."

The "Assessment for Level of Nursing Care," form was reviewed. The form contained areas to document the patient's risk for assault and elopement. The following criteria were marked, "Yes" on Patient 112's form:

Assault Criteria:

Command-type auditory hallucinations to assault or harm others;
Severe paranoia coupled with command auditory hallucinations;
Statements of intent to assault or harm others, with attainable plan;
Pacing in an agitated manner, gesturing angrily; and
5150 as dangers to others.

Elopement Criteria

Severe paranoia coupled with command auditory hallucinations;
Statements of intent to elope with attainable plan;
History of elopement;
Verbalizes intense desire to leave; and
5150 as danger to others and/or gravely disabled.

The form contained "Guidelines for Levels of Interventions." Patient 112 met the guidelines for one to one interventions (one staff member to stay with one patient). There was no evidence in the record of nursing interventions taken between the patient's arrival and his elopement at 4:40 p.m. A "Sitter Log," indicated local law enforcement was called on January 3, 2014, at 4:40 p.m. (to report the patient's elopement).

f. The "Abbreviated Emergency Department Log By Date," was reviewed. The log included an entry for Patient 115, on January 10, 2014, that indicated Patient 115 presented for "medical clearance" and eloped at 4:17 p.m., (four hours and fifty seven minutes after his arrival).

The record for Patient 115 was reviewed on April 17, 2014. According to Patient 115's "Emergency Department Note-Physician," report, the "patient was brought in on a 5150 hold as a danger to others."

The "History of Present Illness," indicated the patient presented with "psychiatric problem...eligible for legal hold. On hold by PD (law enforcement). Patient was violent towards family today."

In the section titled "Psychiatric," the physician documented "Not appropriate mood & affect, not normal judgement Mood and affect: Anxious, Behavior: Relaxed, Judgement: impaired by abnormal thoughts, Abnormal / Psychotic thoughts: Tangential, flight of ideas (a nearly continuous flow of rapid speech that jumps from topic to topic)."

The "ED Discharge Form," indicated the patient eloped and the ED condition was "Unchanged" (indicating the patient was still a danger to others when he eloped).

g. The record for Patient 116 was reviewed on April 17, 2014. Patient 116 presented to the facility on January 12, 2014, at 11:39 p.m., for a "Psych Eval." On January 13, 2014, at 12:30 a.m., a facility Registered Nurse (RN) wrote an "Application for 72 hour Detention for Evaluation and Treatment, (pursuant to Section 5150)," indicating the patient "presented to the ER stating that he is suicidal."

The following was documented in the nursing notes: "Pt seen leaving towards the EMS [Emergency Medical Services -ambulance] door. Security Officer, RN and APRN [Advance Practice Nurse] inform pt (patient) that he is under a psychiatric hold and cannot leave. Pt states he is tired of waiting to go to Oasis and called his mom. APRN states that if he leaves while under a hold, [law enforcement] will be contacted for his safety. Pt leaves ED department. PCC [patient care coordinator] calling [law enforcement]."

The facility policy and procedure titled "Assessment for Need of (Voluntary or Involuntary) Psychiatric Care," was reviewed. The policy indicated: "[Facility] is a non Lanterman-Tetris-Short (LPS), non-designated psychiatric facility. If the treating Emergency Services Physician determines the patient is a danger to himself/herself or to others or is gravely disabled as a result of a mental disorder, the patient may be detained up to 24- hours as per California Senate Bill 916, Chapter 308."
The policy further indicated: "...any patient admitted with psychiatric/behavioral symptoms or a status post attempted suicide event will not be discharged until an appropriate assessment by a 5150 certified employee/physician has been completed..."

The facility policy and procedure titled "72 Hour Hold (5150) Welfare & Institutes (W & I) Procedures," effective November 2, 2011, was reviewed. The policy indicated: "This policy covers the duties and responsibilities of the security Department and its officers in managing patients on 72 Hour Hold under the Welfare & Institution Code 5150." According to the policy "once a patient has met the 5150 criteria the Security Officer along with the ER staff will ensure the following: "Physical restraints shall be used to provide a safe environment for patient, staff and other patients in the ED after other mechanisms have proven unsuccessful." The policy indicated if the patient was agitated, restless or difficult to manage, it would be helpful to get the ED physician involved.

On April 21, 2014, at 3:02 p.m., an acceptable plan of correction was received from the facility, which consisted of;

a. All 5150 patients that have been medically cleared and waiting for transfer to an appropriate facility will be assigned a qualified individual that will be able to recognize, monitor and implement interventions to prevent harm to the patient;

b. For 5150 patients exhibiting behavior consistent with leaving the ED, staff will utilize the following mechanisms (least restrictive first) for detainment:

De-escalation;
Distraction or diversion;
Active communication;
Physical Restraints; and
Chemical Restraints

c. Patients identified as potentially dangerous to self or others, or gravely disabled will have an immediate 5150 evaluation by persons certified to write 5150 holds; and

d. The Security contract was reviewed and security guard roles would change from a sitter role to that of assisting with detainment of 5150 patients.

2. The record for Patient 401 was reviewed on February 18, 2014. Patient 401, a 53 year old male, presented (escorted by police) to the ED on December 7, 2013, at 10:21 p.m., with a chief complaint of, "not doing well," and deemed gravely disabled (unable to care for himself).

The triage note, completed at 11:16 p.m., indicated Patient 401 was, "able to stay awake, and trying to answer questions," but was not able to answer the questions, "well." The note indicated the patient's BP (blood pressure) was elevated at 150/95 (normal 120/80), and his heart rate was increased at 103 beats per minute (normal 60-100). The triage nurse identified the active problems with Patient 401 to be head injury, altered mental status, and an autoimmune disease (a disease that attacks the immune system). The triage nurse assigned Patient 401 a level 2 acuity (emergent - a high risk patient who could easily deteriorate [according to the facility policy titled, "Medical Screening and Triage 5-Level]). Patient 401 was placed in an ED bed at 11:33 p.m.

The nursing assessment, completed at 11:45 p.m., indicated the neurological assessment was WDL (within defined limits), meaning there were no abnormalities (not consistent with the initial triage assessment).

Vital Signs were repeated every one to two hours during the remainder of the ED stay, with no repeat assessment of any system, including the neurological system (that was altered on arrival to the ED).

Nurse's notes for the remainder of the ED stay included the following:

a. 1:15 a.m., the patient was given a urinal for urine collection;

b. 2:30 a.m., the patient was asked to please give a urine sample. The patient was sleeping and had not given a sample;

c. 4:55 a.m., the patient was again asked to give a urine sample, no sample was given. The patient refused catheterization to obtain a sample;

d. 7:30 a.m., the patient was sleeping, easily arousable, pending possible admit, no distress was noted, the patient was calm and cooperative, and security was at the bedside; and,

e. the patient tolerated a meal and was resting comfortably.

According to the ED record, a CXR (chest x-ray) was done, urine was collected and tested, and blood was drawn and tested. Review of the blood test results indicated Patient 401 had a BUN (blood urea nitrogen) of 42.2 (elevated), and a creatinine (to analyze the health of the kidneys) of 1.5 (elevated). Both of these results indicated Patient 401 was dehydrated. Further review of the blood test results indicated Patient 401 had a WBC (white blood cell) count of 11.7 (elevated), indicating he had an infection.

The ED record indicated a saline lock (a catheter placed in the vein to be used for medication administration and to administer fluids intravenously) was inserted on December 8, 2013, at 10:16 p.m. (11 hours and 55 minutes after arrival to the ED).

The ED physician's record, dictated December 8, 2013, at 23 minutes after midnight, indicated the following:

a. The physician accepted (agreed with) the triage assessment;

b. Skin symptoms were negative with no breakdown or abrasions. The skin was intact;

c. The head was normal and atraumatic (no signs of trauma);

d. Neurologic symptoms were negative with no altered level of consciousness and no weakness (inconsistent with the triage assessment); and,

e. The patient was cooperative, with an appropriate mood and affect, and normal judgement.

The physician record indicated Patient 401 was evaluated multiple times during his, "extended," stay in the ED, and he remained stable with no changes in the physical examination. The diagnoses were (blood) infection, non-compliance (not following doctor's orders) with home medications, neglected hygiene, and psychiatric hold. The physician record indicated the patient was admitted to the medical surgical floor in stable condition.

The ED record indicated no focus neurological assessments were performed (for 11 hours and 45 minutes) no additional radiology tests were ordered or done, no visual physical assessment/inspection of the patient's head was performed (in the presence of an altered level of consciousness, according to the reason for seeking ED care) no IV fluids were given for hydration, and no medications were given (including for pain or infection) during the patient's stay in the ED.

According to the record, Patient 401 was admitted to the medical surgical floor from the ED on December 8, 2013, at 11:30 a.m. (13 hours and nine minutes after arrival to the ED). The record indicated on admission the patient's neurological status was not WDL, the patient was not oriented to place and time and he had a flat affect.

The nurse's notes indicated Patient 401 was wearing a bandana on his head, and when it was removed to complete a nursing assessment, a large open wound on the top of the patients head extending into the forehead was revealed. The wound was described as red, white, and yellow in color, weeping, edges separated, measuring 10 cm (centimeters) long, nine cm wide, and two cm deep (approximately the diameter of a soft ball, and one inch deep).

Observation of the photo's taken revealed an open, shiny wound on the frontal top area of the head, extending into the forehead. The wound revealed exposed soft tissue, with no evidence of a cranial bone (skull) present.

The record further indicated Patient 401 was experiencing pain at the wound site.

The record indicated the admitting physician ordered a CT (computerized tomography) of the head, pain medications, IV fluids and antibiotics to treat the medical problems Patient 401 was experiencing.

A review of the Head CT indicated the following abnormalities were found:

a. Bony destruction in the frontal area which may reflect advanced aggressive osteomyelitis (infection) or metastatic (spreading of cancer) disease;

b. Soft tissue swelling or mass extending inside and outside the cranium, which may reflect metastatic disease or phlegmon (an area of inflammation that produces pus);

c. Air-fluid level in the right frontal lobe, which may reflect an abcess; and,

d. Extensive edema in both frontal lobes.

The record indicated Patient 401 was started on pain medication, IV fluids, and antibiotics, and eventually transferred to another acute care facility for a higher level of care.

The facility policy titled, "Assessment and Reassessment Patient Care," was reviewed on February 18, 2014. The policy indicated the goal of the assessment/reassessment process was to provide the patient with the best and most appropriate individualized care and treatment. The policy indicated focused (focusing on the problem the patient presented with) reassessments would occur minimally every two hours. According to the policy, the reassessment would be documented and the plan of care would be revised if necessary. The policy indicated standards of care were consistent with current AHA (American Hospital Association) standards.

The physician and nurses in the ED did not appropriately assess, monitor, or treat Patient 401 to determine the cause of his altered level of consciousness. He presented in the custody of police with a psychiatric hold, and there was no action taken to determine if the cause of his condition was something other than a psychological/psychiatric cause.

3. The record for Patient 402 was reviewed on April 14, 2014. Patient 402, a 75 year old male, presented to the ED on April 12, 2014, at 8:32 p.m. (12 hours after being discharged home from the ED for complaints of abdominal pain, and diagnosed with gallstones), with a complaint of Hematuria (blood in the urine).

The triage assessment, completed at 8:48 p.m., indicated the patient had a history of prostate cancer, DM (Diabetes), HTN (high blood pressure), and neurocysticercosis (a disease that causes stroke like symptoms). The note indicated the vital signs were within normal limits. The nurse assigned Patient 402 a triage level of three (Urgent - a potentially serious illness that requires expedient care [according to the facility policy titled, "Medical Screening and Triage 5-Level]).

The record indicated a nursing assessment, including the systems (not including pain or vital signs) was completed at 2:06 a.m. (five hours and 14 minutes after the triage assessment). The GI (gastrointestinal) and GU (genitourinary) systems were documented as WDL (within defined limits). The record did not indicate where the assessment was performed. There was no evidence the patient was in an ED bed at the time.

The record further indicated Patient 402 was taken to the triage area at 4:14 a.m. (seven hours and 26 minutes after the triage assessment), and vital signs were taken. Patient 402 had a BP (blood pressure) of 169/71 (elevated - normal 120/80). There was no evidence a physician was made aware of the elevated BP. A note made by the triage nurse indicated the patient had, "no pain now post (after) medication." (There was no evidence in the record the patient had been medicated for pain). The note further indicated the patient was tired, and they (the ED staff) were waiting for a physician to call them to admit the patient, the patient was aware, and he was sent back to the waiting room from the triage area.

The record indicated admitting orders were written by the admitting physician at 6:02 a.m. The orders included IV (intravenous) antibiotics, pain medication, nausea medication, blood pressure medication, and insulin for a high blood sugar.

The ED record indicated vital signs were repeated at 8:25 a.m., and again at 10:27 a.m., when Patient 402 was transferred to the medical surgical floor. There was no evidence a focus assessment was performed at these times.

There was no evidence in the ED record Patient 402 was ever placed in an ED bed or seen b

Based on interview and record review, the facility failed to ensure a chest x-ray ordered STAT (immediately) for an Emergency Department (ED) patient (Patient 307) was completed in a timely manner. The failure of the immediate availability of this diagnostic service for three hours resulted in the potential for a direct impact on the overall provision of emergency medical interventions for this patient.

Findings:

A review of Patient 307's record was conducted on April 16, 2014. Patient 307 presented to the ED on March 24, 2014, at 5:41 a.m., with a chief complaint of shortness of breath. A review of the physician's notes indicated, "The patient presents with difficulty breathing...Degree at present severe." Patient 307's medical history included high blood pressure.

A review of Patient 307's physician orders indicated on March 24, 2014, at 6:12 a.m., a chest x-ray (CXR) was ordered.

A review of the ED nurse's documentation dated March 24, 2014, at 8:18 a.m., indicated, "Patient Rounding Comment, 4th call to radiology placed to request CXR."

A review of the radiology department's CXR report for Patient 307 indicated, the date and time the CXR was conducted was March 24, 2014, at 9:03 a.m., three hours after the STAT CXR was ordered.

An interview was conducted with the Radiology Supervisor on April 16, 2014, at 3:45 p.m., who stated the CXR for Patient 307 was late, and should have been completed within an hour of the physician's order.

Based on observation, interview and record review, the facility failed to ensure:

1. Four of seven Emergency Department (ED) Registered Nurses (RNs) (ED RNs 1, 2, 5, and 6) demonstrated competencies in caring for ED patients prior to being given assignments in the ED; and

2. Nursing staff performed care in accordance with written policies and procedures when;

a. Staff did not follow their policy and procedures regarding nursing care for one patient (Patient 203) admitted to the ED under a 5150 hold (when a person is involuntarily confined due to a mental disorder that makes him or her a danger to self and others or is gravely disabled) ;

b. During the triage procedure, the oxymeter probe (a devise used to evaluate the oxygen level of patients that is placed on a part of a patient's body such as an ear, finger, or toe) was cleaned between use for four patients, Patient's 211, 212, 213, and 214.

These failures resulted in unqualified staff working in the ED, and the potential for substandard emergency treatment to be provided.

Findings:

1a. The record for Patient 401 was reviewed on February 18, 2014. Patient 401, a 53 year old male, presented (escorted by police) to the ED on December 7, 2013, at 10:21 p.m., with a chief complaint of, "not doing well," and deemed gravely disabled (unable to care for himself).

The triage note, completed at 11:16 p.m., indicated Patient 401 was, "able to stay awake, and trying to answer questions," but was not able to answer the questions, "well." The note indicated the patient's BP (blood pressure) was elevated at 150/95 (normal 120/80), and his heart rate was increased at 103 beats per minute (normal 60-100). The triage nurse identified the active problems with Patient 401 to be head injury, altered mental status, and an autoimmune disease (a disease that attacks the immune system). The triage nurse assigned Patient 401 a level 2 acuity (emergent - a high risk patient who could easily deteriorate [according to the facility policy titled, "Medical Screening and Triage 5-Level]). Patient 401 was placed in an ED bed at 11:33 p.m.

The nursing assessment, completed by ED RN 1 at 11:45 p.m., indicated the neurological assessment was WDL (within defined limits), meaning there were no abnormalities (not consistent with the initial triage assessment).

Vital Signs were repeated every one to two hours during the remainder of the ED stay, with no repeat assessment of any system, including the neurological system (that was altered on arrival to the ED).

Nurse's notes for the remainder of the ED stay, written by ED RN 1, included the following:

a. 1:15 a.m., the patient was given a urinal for urine collection;

b. 2:30 a.m., the patient was asked to please give a urine sample. The patient was sleeping and had not given a sample;

c. 4:55 a.m., the patient was again asked to give a urine sample, no sample was given. The patient refused catheterization to obtain a sample;

d. 7:30 a.m., the patient was sleeping, easily arousable, pending possible admit, no distress was noted, the patient was calm and cooperative, and security was at the bedside; and,

e. the patient tolerated a meal and was resting comfortably.

According to the ED record, a CXR (chest x-ray) was done, urine was collected and tested, and blood was drawn and tested. Review of the blood test results indicated Patient 401 had a BUN (blood urea nitrogen) of 42.2 (elevated), and a creatinine (to analyze the health of the kidneys) of 1.5 (elevated). Both of these results indicated Patient 401 was dehydrated. Further review of the blood test results indicated Patient 401 had a WBC (white blood cell) count of 11.7 (elevated), indicating he had an infection.

The ED record indicated a saline lock (a catheter placed in the vein to be used for medication administration and to administer fluids intravenously) was inserted on December 8, 2013, at 10:16 p.m. (11 hours and 55 minutes after arrival to the ED).

The ED record indicated no focus neurological assessments were performed (for 11 hours and 45 minutes), no additional radiology tests were ordered or done, no visual physical assessment/inspection of the patient's head was performed (in the presence of an altered level of consciousness, according to the reason for seeking ED care), no IV fluids were given for hydration, and no medications were given (including for pain or infection) during the patient's stay in the ED.

According to the record, Patient 401 was admitted to the medical surgical floor from the ED on December 8, 2013, at 11:30 a.m. (13 hours and nine minutes after arrival to the ED). The record indicated on admission the patient's neurological status was not WDL, the patient was not oriented to place and time and he had a flat affect.

The nurse's notes indicated Patient 401 was wearing a bandana on his head, and when it was removed to complete a nursing assessment, a large open wound on the top of the patients head extending into the forehead was revealed. The wound was described as red, white, and yellow in color, weeping, edges separated, measuring 10 cm (centimeters) long, nine cm wide, and two cm deep.

Observation of the photo's taken revealed an open, shiny wound on the frontal top area of the head, extending into the forehead. The wound revealed exposed soft tissue, with no evidence of a cranial bone (skull) present.

The record further indicated Patient 401 was experiencing pain at the wound site.

The record indicated the admitting physician ordered a CT (computerized tomography) of the head, pain medications, IV fluids and antibiotics to treat the medical problems Patient 401 was experiencing.

A review of the Head CT indicated the following abnormalities were found:

a. Bony destruction in the frontal area which may reflect advanced aggressive osteomyelitis (infection) or metastatic (spreading of cancer) disease;

b. Soft tissue swelling or mass extending inside and outside the cranium, which may reflect metastatic disease or phlegmon (an area of inflammation that produces pus);

c. Air-fluid level in the right frontal lobe, which may reflect an abcess; and,

d. Extensive edema in both frontal lobes.

The record indicated Patient 401 was started on pain medication, IV fluids, and antibiotics, and eventually transferred to another acute care facility for a higher level of care.

The facility policy titled, "Assessment and Reassessment Patient Care," was reviewed on February 18, 2014. The policy indicated the goal of the assessment/reassessment process was to provide the patient with the best and most appropriate individualized care and treatment. The policy indicated focused (focusing on the problem the patient presented with) reassessments would occur minimally every two hours. According to the policy, the reassessment would be documented and the plan of care would be revised if necessary.

The file for ED RN 1 was reviewed on February 18, 2014. There was no evidence of ED bedside competency demonstration in her file.

During an interview with the ED Director on February 18, 2014, at 10:30 a.m., the director stated ED RN 1 was a, "relatively new nurse," who, "had potential." The director stated she recognized a need to provide educational opportunities for the nursing staff, and she had been requesting support in accomplishing that, but it had nor yet been approved.

ED RN 1 did not appropriately assess or monitor Patient 401. There was no evidence in the record ED RN 1 advocated for Patient 401 when there were signs of dehydration and infection present. Patient 401 presented in the custody of police with a psychiatric hold, and there was no evidence of recognition that there may be a cause other than a psychological/psychiatric problem.

b. During a tour and observation of the ED conducted on April 15, 2014, at 9 a.m., an interview with ED RN 2 was conducted. ED RN 2 stated she worked in the intensive care unit (ICU) at the facility, but sometimes floated to the ED.

A review of ED RN 2's personnel file, was conducted. ED RN 2's file contained annual skill competencies for the ICU department, but not for the ED. A review of both the ED and ICU required skills list was conducted. The ED skills list included two skill requirements which were not included on the ICU skills list. These two skills were Point Of Care testing to perform a urine dipstick and the Point Of Care testing to perform a HcG (human chorionic gonadotropin) pregnancy test.

A review of the facility's mandatory requirements for an ED nurse was conducted. An ED Triage Course was included as a current mandatory competency.

A review of ED RN 2's personnel file failed to show that RN 2 had the competency of an ED Triage Course.

An interview was conducted with HRS (Human Resources Staff) 1 on April 16, 2014, at 2:30 p.m., who stated the Point Of Care testing skills, and the ED Triage Course had not been completed by ED RN 2.

c. During a tour of the ED conducted on April 14, 2014, at 9:55 a.m., RN 5 and RN 6 were observed caring for patients.

During a concurrent interview with RN 5, RN 5 stated she had been working in the ED for a year and four months.

During an interview with RN 6, on April 14, 2014, at 11 a.m., RN 6 stated he had worked in the ED since December 2013, approximately 4 1/2 months. RN 6 stated he was a "Traveler" (a nurse that works for an outside agency contracted by the facility).

A review of the mandatory requirements for an ED nurse and for a contracted ED nurse was conducted. An ED Triage Course was included as a current mandatory competency. The requirements indicated an ED Triage Course was mandatory within three months of employment for a contracted ED nurse.

The personnel files of RN 5 and RN 6 were reviewed on April 16, 2014, at 2:30 p.m., with HRS 2. There was no documentation that indicated RN 5 and RN 6 had completed a ED triage Course.

In a concurrent interview with HRS 2, the HRS reviewed the files for RN 5 and RN 6 and stated the ED Triage Course had not been completed by RN 5 and RN 6.



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2.a. A tour of ED was conducted on April 14, 2014, at 10:05 a.m. Patient 203 was observed dressed in a shirt, pants,and shoes. Patient 203 had a watch on his left wrist and and what appeared to be an object in the right pocket of his pants.

During an interview with Security Officer 5 (SG 5), on April 14, 2014, at 10:15 a.m., SG 1 stated she was assigned to watch Patient 203 because he was on a 5150 hold.

The record for Patient 203 was reviewed on April 14, 2014. Patient 203 presented to the ED on April 14, 2014, at 1:11 a.m., with the chief complaint "very disturb(ed)."

The nursing document titled "ED Triage" dated April 14, 2014, at 1:16 a.m., indicated "Mom states pt has been "acting crazy."

The nursing document titled "Patient Assessment System" dated April 14, 2014, at 3:01 a.m., indicated "Pt admits to homicidal ideation's (thought of wanting to kill) to family members."

The document titled "ED Physician" dated April 14, 2014, modified at 6:33 a.m., indicated Patient 203 was on a "5150 psychiatric hold" and had been diagnosed with "Acute bi-polar disorder, acute schizophrenia (mental disorders)."

During an interview with Registered Nurse 3 (RN 3), on April 14, 2014, at 10:24 a.m., RN 3 was asked if patients' with a behavioral health problem were allowed to have access to personal belongings. RN 3 stated "We don't take their clothing if they say no."

The facility policy and procedure titled "Nursing Care for Behavioral Health Patient in the ED" effective March 19, 2009, indicated patient's personal items (clothing, valuables,etc.) will be removed from the patient's access.

2. b. An observation of the triage process was conducted on April 15.2014, beginning at 10:00 a.m. RN 4 was observed triaging four patients (Patient 211, 212, 213, and 2014). RN 4 had checked all four patient's oxygen level using the same oxymeter probe. RN 3 did not clean the probe between patient use.

During an interview with RN 4, on April 15, 2014, at 10:30 a.m., RN 4 stated it was the facility's practice to "Clean the oxymeter probe with a disinfective wipe between patients." RN 4 stated "I didn't do that. I guess I was just razzled by today..."