HospitalInspections.org

Based on interview and record review, the facility failed to provide emergency care necessary to meet the needs of 4 (Patient #'s 1, 2, 10, and 11) of 10 sampled outpatients. The facility failed to:

A. ensure physicians provided clear documentation of what their plans for treatment were for patients presenting with complaints of severe abdominal pain and syncope (fainting/or temporary loss of consciousness). There was no clear documentation in the charts to determine if the patients received thorough assessments and treatment by the Emergency Department (ED) physicians.


B. ensure nursing staff documented consistent vital signs and follow-up pain assessments after administration of pain medication. The nursing staff failed to document a follow-up assessment after administration of medication for nausea.


C. ensure nursing staff documented a reassessment or vital signs after administration of anti-anxiety agents.


This deficient practice had the likelihood to cause harm to all patients presenting to the ED.


Findings:


Review of the ED (Emergency Department) medical record of Patient #10 revealed, she was a 40-year-old female who presented on 04/08/2019.

According to the "EMERGENCY DEPARTMENT SIGN IN SHEET" Patient #10 presented for "abdominal pain, stomach, unable to hold food down."

According to the nursing triage assessment dated 04/08/2019 at 8:38 a.m., Patient #10 presented with complaints of abdominal pain for the past two weeks which worsened in the last 2 days. Patient #10 complained of vomiting and diarrhea.

Review of the triage assessment revealed Patient #10 had an acuity level of 3 (meaning urgent). Vital signs were taken and Patient #10 had a pain level of 9 (meaning severe) of 10 point pain scale. Patient #10 was described as having tenderness to the left and right lower quadrants of the abdominal area.


Review of the physician's examination at 8:54 a.m., revealed the following:

"Presents for evaluation of lower abd pain and cramping over the past 2 weeks with occasional diarrhea. Has chronic abd issues with off and on vomiting. Over past 2 weeks says that feels pressure in lower abd. Recently stopped long term use of Depoprovera due to migraines and has not resumed menstrual cycle. No fever. Says pain is constant. Off and on vomiting. Denies any urinary complaints." ..


There was no documentation of what the physician's plan of treatment during the ED visit was as a result of the assessment.

Review of the chart revealed, physician orders for a urinalysis and pregnancy test. Both test was negative.

There was no documentation of medication or any other test given during the ED visit.

There was documentation on discharge information at 9:05 a.m. of the following:

"VS nl (vital signs normal), does not appear in any painful distress and abd does not appear surgical on physical exam. Discussed with patient and would like to continue work up as outpatient with OB/GYN (obstetric/gynecologist) as in discussions told that likely is a result of the uterus with recent cessation of Depo."

There was no documentation of another set of vital signs on the chart for Patient #10 to show they were normal.

There was no documentation of a gynecological exam or any other test on Patient #10 to determine if there was an internal reason for the pain.

According to discharge notes Patient #10 was discharged home at 9:27 a.m., with a diagnosis of lower abdominal pain. Patient #10 was discharged with a new prescription for the gastrointestinal medication Dicyclomine.

During an interview on 05/02/2019 after 3:00 p.m., Staff #3 confirmed the missing documentation in the charts. Staff #3 reported there was a place in the computer for the physicians to document their plan. It was not being completed.


Review of the ED (Emergency department) on Patient #2 revealed, he was a 58-year-old male who presented on 01/08/2019 at 6:01 p.m.

According to the nursing triage assessment dated 01/08/2019 at 6:22 p.m., Patient #2 presented with complaints of left sided abdominal pain. According to documentation Patient #2 was seen earlier today with flank pain that the computed tomography scan showed kidney stone were resolved.


Review of the triage assessment revealed Patient #2 had an acuity level of 3 (meaning urgent). Vital signs were taken and Patient #2 had a pain level of 10 (meaning severe) of 10 point pain scale.

Review of vital signs at 6:36 p.m., revealed Patient #2 had a pain level of 8 (severe pain). There was documentation that nursing administered the pain medication Toradol intravenously to Patient #2 at 6:36 p.m.

According to notes at 9:09 p.m. (2.5 hours later), revealed Patient #2 was discharged home at 8:39 p.m., and had a pain level of 2.

During an interview on 05/02/2018 after 10:30 a.m.., Staff #9 (ED nurse) reported they were supposed to reassess patients from 30 minutes to an hour after administration of pain medication.

During an interview on 05/02/2019 after 3:00 p.m., Staff #3 confirmed the missing documentation in the charts. Staff #3 reported she could not find documentation of the follow-up pain assessment after administration of the pain medication.


39801

PATIENT #1

Review of the medial record for Patient #1 revealed the following:

The Emergency Services abbreviated care report showed the Injuries/Chief complaint for Patient #1 as Chest pain/Abdominal pain. Pain level was 8/10.

The Emergency Department sign in Sheet showed the reason for visit as "MVC". The patient was signed in at 4:14. There was not a notation for AM or PM.

The Triage note was dated 1/11/2019 at 5:55 PM. The Chief complaint was MVC. Patient #1 was assigned acuity level 3 (Urgent). The triage assessment documented the following, "chest sore to palpation abd soft tender, r quad abd no hip pain." There was no pain scale noted on the triage sheet. The flow sheet vital signs at 5:57 PM were Blood Pressure 111/95, Oxygen Saturation 100% Pulse 96, Respiration 18, temperature 97.9, Pain level was documented as 8.

The ED (Emergency Department) Initial Assessment Notes documented for Patient #1 stated "Gastrointestinal bowel sounds normoactive; no nausea and vomiting; continent; fecal; rectal tone; intact; tender r quad."

The Ed provider Assessment was documented at 1-11-2019 at 4:20 PM. The chief complaint for Patient #1 was documented as "MVC". The ROS (Review of System) documented the patient reports abdominal pain but reports no nausea, no vomiting, no constipation, normal appetite, no diarrhea, not vomiting blood, no dyspepsia, and no GERD. The Physical Exam on Patient #1 for the Abdomen documented the following, "lower abdominal wall tenderness consistent with a seatbelt injury."

There was no documentation of what the physician's plan of treatment during the ED visit was as a result of the assessment.

Physician orders noted in the chart for Patient #1 were CBC, UA, CMP, HCG. Imaging orders show Chest X- Ray. There were no Imaging orders for the abdominal pain complaint/assessment.


Medication Orders for Patient #1 were as follows:

Acetaminophen 1000 mg once now 1/11/2019 4:56. There was no indication documented for the medication.
Ketorolac Intravenous (IV) 30mg once now 1/11/2019 6:57 PM. There was no indication documented for the medication.
Ativan 1 mg once now 1-11-2019 7:09 PM. There was no indication documented for the medication. There was no documentation in the physician notes for any behavioral symptoms that would indicate a reason the medication was given.

Medication Administration for Patient #1 were as follows:

Acetaminophen 1000 mg once now 1/11/2019 5:10 PM. There was no indication documented for the medication. There was no pain level documented at administration. There was no follow up pain level documented.

Ketorolac Intravenous (IV) 30mg once now 1-11-2019 at 7:01 PM. There was no indication documented for the medication. There was no pain level documented at administration. The next pain level documented was 1-11-2019 at 7:30 PM. The pain level was documented as 5.

Ativan 1 mg once now 1-11-2019 7:45 PM. There was no indication documented for the medication. There was no documentation in the nurse notes of the patient's behavior at this time. There is a note in the chart at 7:58 PM that states, "Chatting on the phone, in no acute distress". There were no vital signs documented until 8:10 PM; 25 minutes later.

Patient #1 was discharged at 8:30 PM. The Discharge Instructions for the Patient #1 documented, "Rest for next two days. Follow Up with your doctor next week. The Discharge Vitals were listed as, Blood Pressure 106/66, Pulse 100, Respirations 16, Temperature 97.9, Oxygenation Saturation 98%, Pain scale 5. There were no discharge instructions or mention of abdominal pain in the discharge summary. Patient #1 was given a prescription for Tylenol #3 #20 one PO 4 times a day for pain. The diagnosis was neck strain, MVC.



PATIENT #3

The Emergency Department sign in Sheet did not show a reason for the emergency room visit. The arrival time documented was 12:57 PM.

The Triage note on 1-13-2019 at 10:23 AM for Patient #3 showed a chief complaint of stomach pain, vomiting blood for 2 days. The acuity level was 3 (Urgent).

The flowsheet vital sheet for Patient #3 documents vitals at 10:24 AM. The vital signs were Blood Pressure- None listed, Pulse 55, Respiration 18, Temperature 98.0, Pain Scale 7.

The ED provider Assessment was documented on 1-13-2019 at 10:32 AM. The chief complaint for Patient #1 was documented as stomach pain, vomiting blood for 2 days.

The ROS (Review of Systems) documents, "Patient reports abdominal pain, nausea, and vomiting".

There was no documentation of what the physician's plan of treatment during the ED visit was as a result of the assessment.

Physician orders noted in the chart were CBC, CMP, CT of the Abdomen and Pelvis with contrast.


Physician medication orders noted in the chart included:
"Lidocaine Mucosal Liquid 2% 20 ml once now 1-13-2019 10:36 AM. There was no indication documented for the medication.

Zofran ODT 4 mg once now 1-13-2019 10:36 AM. There was no indication documented for the medication.

The Medication Administration Record included documentation of the following medications:

"Lidocaine Mucosal Liquid 2% (Topical anesthesia for inflamed mucous membranes) 20 ml, 1-13-2019 at 11:05 AM. There was no documentation in the nurse notes of the indication for giving the medication, nor was there a reassessment after the medication was given.

Zofran ODT 4 mg (Anti-nausea) once, 1-13-2019 10:36 AM. There was no documentation in the nurse notes of the indication for giving the medication, nor was there a reassessment after the medication was given.

There were no vital signs documented in the chart after medication administration. There were no vital signs or pain level documented throughout the ED visit or at discharge."


PATIENT #11

The Emergency Department sign in sheet documented the reason for visit as Dizzy-weakness. The patient was signed in on 2-3-2019 at 7:35 PM.

The Triage note was dated 2-3-2019 at 7:40 PM. The Chief complaint for Patient #11 was documented as weakness. Patient #11 was assigned an Acuity level of 3 (Urgent). The triage assessment noted the following: "EMS report - Dizzy and weak, Events leading to ED presentation - Pt states weakness for 3 days now. Tonight dizzy and weak. Neurological - alert; disoriented; briefly disoriented and unable to answer our questions, lasted maybe one minute. Neuro intact."

The vital signs documented on the Flowsheet were as follows:

"2-3-2019 7:40 PM - Blood Pressure 207/109, Pulse 60, Oxygen Saturation 94%, Respiration 16, Pain level was not documented.

2-3-2019 7:47 PM - Blood Pressure 179/78, Oxygen saturation 94%.

2-3-2019 8:00 PM - Blood Pressure 214/111

2-3-2019 8:30 PM - Blood Pressure 187/78, Pulse 59, Respiration 14

2-3-2019 8:35 PM - Blood pressure 180/75, Pulse 75, Respiration 16, Oxygen Saturation 95%.


There was no documentation of vital signs after 8:35 PM. Patient #11 was discharged over 1 hour later. The abnormal vital signs were not addressed in the physician or nurse notes.


The ED Nursing Initial Assessment Notes dated 2-3-2019 at 7:40 PM, noted the following: "Neurological alert, cooperative; speech clear; pupils equal, react to light and accommodation (PEERLA); disoriented - briefly disoriented and unable to answer questions, lasted one minute approximately. Not sure of today's date but knows it is February and where she is at. Moves all extremities equally/ equal strength."

The ED provider Assessment was dated 2-3-2019 at 7:50 PM. The Chief complaint for Patient #11 was documented as weakness. The ROS (Review of Systems) noted the following, "Patient reports weakness and dizziness but report no loss of consciousness, no seizures, and no tremor .... Patient #11 is a 95-year-old patient ...Neurologic - Gait and Station: normal gait, Cranial nerves: grossly intact. Sensation: grossly intact. Coordination and Cerebellum: no tremor. Psychiatric: Mental status - active and alert and normal mood. Orientation: to time, place and person." This psychiatric assessment did not mirror the EMS assessment or the nurse assessment.

There is no documentation of what the physician's, plan of treatment during the ED visit was as a result of the assessment.

The Nursing Notes documented the following:

"2-3-2019 7:40 PM - Arrived via EMS, alert on arrival. While talking with patient she paused for approximately one minute and was unable to respond verbally. Neuros intact. Slightly disoriented as to the exact date today. She does know it is February and that she is at the hospital.

2-3-2019 8:28 PM - called to the bedside, Pt feels as though she will pass out once again. Awake but eyes closed, color pink, skin warm and dry. Dr. Cox at the bedside to evaluate Pt.

2-3-2019 8:30 PM - asked about the possibility head CT, MD indicated no at this time.

2-3-2019 9:18 PM- MD in to speak with Pt and son.

2-3-2019 9:28 PM- Son had expressed his opinion that Pt need to stay overnight with the MD previously.

2-3-2019 9:35 PM - Out via wheelchair with pt. Son taking back to Enchanted Pines. Previously ambulated Pt in the hallway with assistance and Pt had no difficulties/dizziness/weakness."

There was no documentation of the above listed events in the physician notes.

The Physician orders noted in the chart were as follows:
CBC, CMP, Urinalysis, Troponin, EKG

Patient #11 was discharged home at 9:35 PM. The discharge instructions noted, "increase fluid intake. Follow up with Dr. Kelly in 1-2 days for re-evaluation."

The ED Shift notes dated 2-3-2019 at 9:35 PM noted the following, "Calm, but confused. Oriented to person and place but not time."

Staff #3 confirmed the missing documentation. Staff #3 was not able to find the information in the printed or electronic medical record.


Review of the QAPI meeting minutes for January 2019 revealed documented on following on PI Projects:
"Problems identified and data collection implemented Oct 2018 -
4) ED documentation compliance

Recommended Action - Continue to monitor Performance Improvement Projects. Resolution/Follow Up - No action needed at this time"


Staff #3 was asked what documentation compliance issues were identified. Staff #3 provided Quality dashboard sheets. Review of the Quality dashboard for March 2019 revealed the following:

"Nursing -
Pain Assessment & Documentation Completed - showed 100% compliance
Pain reassessment after medication - showed 81% compliance


Review of the facility Policy Titled, "ASSESSMENT AND REASSESSMENT: dated July 15,2018 revealed the following:

"A.2. Reassessment

a. Reassessment is a component of the patient plan of care and is conducted at key determinate events as well as throughout the care continuum. Reassessment is the evaluation of patient response to treatment and care in order to determine the appropriateness and effectiveness of care decisions.

...D.2. Reassessment: Reassessment determines the patient's response to care and treatment. Patient reassessment is ongoing and may be triggered at key decisions points and at any interval specified by the clinical disciplines directly involved in providing patient treatment and/or care. Each patient is to be reassessed according to discipline-specific guidelines. Patient reassessment will occur at specified, regular intervals related to:

a. patient treatment/procedures

b. patient response to treatment/procedures

c. significant change in the patient condition

d. significant change in the patient diagnosis

e. discharge planning where appropriate in the scope of care of the applicable department


.... F.2.c. The reassessment process includes, but is not limited to review of the following parameters as needed depending on changes in the patient's progress:

1. Physical: head to toe assessment

2. psychosocial

3. wounds, dressings, invasive lines

4. activity

5. patient care needs

6. response to treatment

7. skin integrity/pressure ulcers

8. nutritional/malnutrition status

9. functional status

10. pain - location, type, intensity, change

11. fall risk

12. aspiration risk

13. DVT/VTE risk

14. Other risk assessments as needed if the patient's status changes"

Based on observation, interview, and record review, the facility failed to ensure the infection control officer developed a system that maintained a clean, orderly, and sanitary environment for 13 of 13 areas in the emergency room observed. The facility failed to ensure the triage room, clean supply room, nurse desk, exam room 5, exam room 6, precipitous birth cart, Intravenous supply cart, trauma room #1, trauma room #2, medication room, patient bathroom, dirty utility room, and Exam Room #4 were clean and sanitary.

Cross Refer to Tag C0225

Based on observation, interview, and record review, the facility failed to ensure the infection control officer developed a system that maintained a clean, orderly, and sanitary environment for 13 of 13 areas in the emergency room observed. The facility failed to ensure the triage room, clean supply room, nurse desk, exam room 5, exam room 6, precipitous birth cart, Intravenous supply cart, trauma room #1, trauma room #2, medication room, patient bathroom, dirty utility room, and Exam Room #4 were clean and sanitary.

This deficient practice had the likelihood to cause harm in all patients.


Findings:

TRIAGE ROOM

There was a tear in the vinyl covering of the arm board on a chair that was for patient use. There was a buildup of dust, dirt, and debris on the metal frame where the linoleum and wall connected at the base. There was a blood pressure cuff stored inside a drawer in the desk of the triage area that was available for patient use. There was no label/indicator to show if the cuff was clean or dirty. The desk in the triage room had rust on the metal frame and drawer handles. The baseboard on the wall outside the triage room had a build-up of wax, dust, dirt, and debris.


CLEAN SUPPLY ROOM

There was a Biohazard box stored on the floor under the rack that stored crutches for patients. There were patient crutches stored on the carpet floor between a metal supply closet and the wall.


NURSES DESK

There was a computer used to connect with telemedicine doctors that was stored next to the nurse desk. The keyboard, metal rack on the top and the base were covered in dust, dirt, and debris. There was a mobile computer used by the nurses to chart that carried into patient rooms. There was a heavy build of dust, dirt, and debris on the keyboard. The base of the workstation cart was coated in dust. The wall in front of the nurse station had vinyl corner guard that was separated from the wall exposing sheetrock. The corner on the opposite side of the wall had scrapes and holes exposing the sheetrock. The wall in the hallway in front of the nurse's desk had splatters of a red/orange substance that appeared to be blood splatters. The wall had scraped/missing chips of paint exposing the sheetrock. A stepping stool that was for patient use, was stored in front of the nurse's desk. The top of the stool had a non-slip surface covered in dust, dirt, debris, and white colored substance. The metal frame was coated in rust.


EXAM ROOM 5

On the wall outside of Exam room 5, there was a buildup of dust, dirt and debris. The vinyl baseboard was separated from the linoleum and there was a buildup of dust, dirt, and debris in the crevice. On the wall outside of Exam Room 5, the walls/corners had scraped/missing chips of paint that exposed the sheetrock. On the opposite wall outside of room 5 and next to the patient Linen Cart, the walls had scraped/missing chips of pain that exposed the sheetrock.


EXAM ROOM 6

The sheets on the stretcher had holes in them. The mattress on the stretcher had tears and cracks in the vinyl covering. The stretcher was in a room and ready for patient use. There was a chair in the room sitting beside the stretcher that had a tear in the vinyl covering.


PRECIPITOUS BIRTH CART

There was a metal cart used to store supplies for a precipitous birth. The cart had rust on the frame and wheel casters. There was a Welch Allyn wall Otoscope/Ophthalmoscope used to examine patient eyes and ears that was stored uncovered. There was no way to determine if it was clean or dirty. There was a flowmeter used to deliver oxygen to the patients, that was stored uncovered and was not labeled clean or dirty.


INTRAVENOUS SUPPLY CART

A cabinet that stored Intravenous supplies had a buildup of dirt, dust, and debris along the bottom rails of the cart.


TRAUMA ROOM #1

There was an intravenous Pressure Infuser bag stored in a cabinet. The cabinet shelf it was stored on had brown colored stains and a buildup of dust.


TRAUMA ROOM #2

The was a brown/red colored stain that appeared to be blood on the shelf directly above the oxygen masks. There was a red colored stain that appeared to be blood on the mayo stand metal frame. There was a rust colored stain in the sink. Under the sink in a cabinet, there was a brown colored stain that appeared to be a water stain.


MEDICATION ROOM

There was an ice machine stored next to the patient medication refrigerator. The ice dispenser slot had a buildup up of lime scale and debris. On the side of the ice machine, the slot for the filter was missing. There was a label on the side of the machine that gave instructions of the required filter changes. Staff #3 confirmed there was no filter on the machine. The inside of the ice machine had a heavy buildup of lime scale, dust, dirt, and debris. The vent on the front of the machine had a buildup of lime scale and debris. The sink had a buildup of rust and debris. There were red colored stains in the basin of the sink. There was a cart that stored supplies used for wounds/laceration repair. The cart contained bottles of open betadine. The bottles were single use only. The cart contained several vials of Iodoform packing that had been opened and placed back in the cart for patient use. There was a water fountain that was used for patients and employees. The fountain was coated in dust, dirt, and debris. The floor behind the water fountain had a buildup of dust, dirt, debris. There was what appeared to be a food item (nut) on the floor in the corner.


PATIENT BATHROOM

The commode in the patient bathroom had red colored stains on the lid and outside basin that appeared to be blood. There was a buildup of wax, dust, dirt, and debris on the floor and corners. The ceiling tile frames were coated in rust. One frame next to the vent was loose and hanging freely from the ceiling.


DIRTY UTILITY ROOM

Dirty Utility Room - The hopper/sink in the room had brown colored stains in the basin. There was a metal rack that stored empty oxygen cylinders. The cylinders were uncovered and exposed to biohazard materials. The floor underneath the rack had brown colored stains. The room was in disarray. On top of the counter there was a cardboard box with cleaning supplies, bags of rags/towels in a clear plastic bin, a full sharps container, a used ink printer cartridge in a cardboard box, and several plastic trays. Above the cabinet on a wall, there was a shelf that had an empty biohazard bin, a flashlight, a box of biohazard bags, Sani-wipes, and dishes (Yeti cooler, bowl, and utensil). A cabinet underneath the sink had brown colored stains on the cabinet floor that appeared to be water stains. The floor next to the cabinet had a buildup of wax, dirt, and debris. The walls had brown colored stains and scraped/missing chips of paint.


Staff #3 Confirmed the above findings


Review of the 2019 Infection Control rounds revealed the following:

March 2019
ER - Clean appearance w/out dust or debris. All wipeable surfaces are clean and Intact. The response is marked NO. March 2019

April 2019
ER - Clean appearance w/out dust or debris. All wipeable surfaces are clean and Intact. The response is marked NO.

There was no follow up noted. There were no actions taken on the deficiencies noted.


10135

During an observation on 05/02/2019 after 10:30 a.m., the following was found:


TRIAGE ROOM

The stool in the triage room had a broken wheel and the metal legs on the stool were rusted. The leather covering on the seat of the stool had rips. The stool could not be sanitized.

A basin was stored in a drawer with clean, unwrapped 4 x 4 dressings stuffed in the basin. The dressings were not covered to protect them from dust and contamination


CLEAN SUPPLY ROOM

The clean supply room had a mixture of non-sterile and sterile supplies stored together. There were sterile supplies that were in sterile wraps and in peel packets stored on the shelves in the room. There were supplies on the floor underneath the shelves.

The flooring in the room was carpeting. There was no way the flooring could be sanitized.


HALLWAY OF EMERGENCY DEPARTMENT

A soiled linen cart which contained soiled linen was stored right underneath a rack with patient charts in it.

A supply cart was stored in the hallway next to the nursing station. Two open bottles of Ultrasound gel were in the cart and did not have the open date logged on them.

According to the manufacturer guideline (Auspice) revealed the following instructions:

"Shelf Life and Storage of Aquasonic Ultrasound Transmission Gel"

"..Since there is no effective way to determine whether an opened bottle of gel has been contaminated general guidelines are that gel should be marked to expire 28 days after open. Using a warmer does not impact the expiration time.."

A Doppler was stored in the cart. The bag it was stored in was heavily soiled with dried stains.

An intravenous pump was stored on top of the cart. It was covered with a plastic bag to indicate it was clean. The pump was soiled with remnants of soiled tape and brown substance.

A Dynamap used to take vital signs on patients was next to the cart in the hallway. It was covered with a plastic bag to indicate it was clean. The base of the equipment was soiled with dust and the wheel casters on the equipment were rusted.

The Dynamap had a blood pressure cuff already attached and it was not covered to indicate it was clean.
Staff #9 was observed to take the Dynamap into a patient's room and use it. When he exited the room he was questioned about the equipment. Staff #9 confirmed that he did not know if the blood pressure cuff was clean. He just assumed it was because they were supposed to clean them in between patients.


EXAM ROOM #4

The baseboards outside the room were soiled with a buildup of dirt.

The frame to the door of room had separated. The seperated area was covered with soiled tape.

A wall in front of the nursing station was missing chunks of the plaster. The baseboard in the same area had separated from the wall.


TRAUMA ROOM #1

The wheel casters on the blanket warmer were rusted.

A step stool next to the warmer was heavily rusted.

A soiled blood pressure cuff was attached to the wall sphygmomanometer in the room.

The ceiling examination light over the bed was covered in rust. The ceiling plaster around the examination light was cracked and hanging down.

The Pediatric emergency crash cart had plastic bins which were soiled with spills.

A bin containing emergency medications on the Pediatric crash cart was soiled with hair.

Loose electrocardiogram (EKG) electrode pads were stored in a drawer. They were not contained in their packet.

According to the manufacturer guidelines the electrodes had a 30-day shelf life once the package was opened


EXAM ROOM #1

A metal soiled linen cart was in the room. The base of the cart was rusted.

The patient's bed frame in the room was rusted. The bottom of the mattress was soiled with a brown substance.

An intravenous pump was at the bedside and covered with a plastic bag to indicate it was clean. The cord attached to the equipment was soiled.

A plastic bag was stored at the bedside with EKG electrode pads in it. The pads had been removed from their original package.

A pulse oximeter was in the room and the inside of the equipment was soiled with dried blood.

A metal table in the room had wheel casters that were covered in rust.

The cabinet door underneath the sink area was in need of repair. The particle board underneath the top covering could be seen. The tile floor in front of the sink had rips and gashes and was in need of a repair.


BEHIND THE NURSING STATION

There were patient Styrofoam cups, cup lids, and an ice scoop stored on an uncovered shelf behind the nurse's station. Manuals were stored above the supplies. The shelf was stored up against a wall at the entrance of the staff's bathroom.


Staff #3 confirmed the observations.

Based on observation, interview, and record review, the facility failed to ensure proper temperature and ventilation in the Main Emergency Department (ED) supply room from January - April 2019 ( 4 months). The facility failed to:

A. ensure staff kept the temperature within range as per their policy.

B. ensure staff documented proper notification was made and action was taken to get the temperature back in range.

C. ensure staff logged humidities consistently.

This deficient practice had the likelihood to affect all patients presenting to the ED.


Findings:

During an observation on 05/02/2019 after 10:30 a.m., the following was found:

The clean supply room had a mixture of non-sterile and sterile supplies stored together. There were sterile supplies that were in sterile wraps and in peel packets stored on the shelves in the room. There were supplies on the floor underneath the shelves.


Review of the temperature and humidity logs from January- April 2019 revealed the following:

January - 4 days the temperature was out of range;

February- 5 days the temperature was out of range and 1 day the temperature nor the humidity was logged;

March- 2 days the temperature was out of range and 2 days the temperature nor the humidity was logged;

April-May 2019- 8 days the temperature was out of range and 1 day the temperature nor the humidity was logged;


There was no documentation of what was done to get the temperatures back within range.

Staff #3 confirmed the observations.


Review of the instructions on the form revealed the following:

"Sterile storage should be maintained at 72-78 degrees Fahrenheit..and with humidity no greater than 60 %. If temperature or humidity readings are out of range for any room. Immediately notify the OR Director and Maintenance and document any actions taken in the space provided

Based on interview and record review, the facility failed to have procedures in place to address medication errors in the Emergency department (ED).

The facility failed to implement their policy on reviewing and determining why medications errors were made and could be avoided.

This deficient practice had the likelihood to cause harm to all patients presenting to the ED..


Findings:

Review of Occurrence reports from March 2019 revealed the following:

Two incidents dated 3/31/2019 revealed a nurse made two medication errors during her shift. The nurse gave the wrong dose of a narcotic and on another patient gave the wrong medication.

Review of the reports revealed no documentation of what the resolution was or if a root cause analysis was performed.

There were no tracking logs for March and April 2019.


During an interview on 05/02/2019 after 2:40 p.m., Staff #3 confirmed there was tracking done after April because someone else took over the incidents. Staff #3 confirmed there was no resolution documented on the incidents.


During an interview on 05/02/2019 after 3:00 p.m., Staff #5 (Quality) confirmed there was no tracking and trending being done on incidents. Staff #5 (Quality) reported that she did not find out the reasons as to why the medication errors were made on 03/31/2019.


Review of a facility's policy named "Nursing Care Standards "dated 07/15/2018 revealed the following:

"..Situation (occurrence) reports that include medication administration and treatment error incidents are reviewed to determine why errors are made and how they can be avoided.

From these observations, necessary changes in clinical nursing practices are planned and implemented.."


Review of a policy named "Root Cause Analysis" dated 07/15/2018 revealed the following:

..Objectives of the root cause analysis are:

To identify those causative issues, systems or processes that represent core reasons for occurrence of the event.

To develop an action plan that will prevent recurrence of the event.

To implement the action plan, monitoring the plan's effectiveness periodically.

To assure the event will not be repeated.