HospitalInspections.org

Based on findings from document review and interview, in 2 of 4 personnel files, the hospital did not ensure emergency department (ED) staff had current required training in accordance with New York State Codes, Rules and Regulations. This lack of current training could potentially lead to inadequate care of patients presenting to the ED with a emergency medical condition.

Findings include:

-- Per New York State Codes, Rules and Regulations Title 10 (405.19), it requires ED staff (providers and nurses) to be currently trained in Advanced Cardiac Life Support (ACLS).

-- Per review of Staff A's (ED Medical Director) personnel file (employed since 9/2007), it lacked evidence Staff A had current training in ACLS.

-- Per review of Staff B's (ED RN/Charge Nurse) personnel file (employed since 7/1976), it lacked evidence Staff B had current training in ACLS.

-- Per New York State Codes, Rules and Regulations Title 10 (405.19), it requires ED nurses to be currently trained in Pediatric Advanced Life Support (PALS).

-- However, per review of the job description for registered nurses (RNs) in the ED did not require PALS certification.

-- During interview of Staff C (Director, Chief Patient Safety Officer Quality and Patient Safety) on 2/8/17 at 5:30 pm, he/she acknowledged the above findings.

Based on findings from document review and interview, the hospital does not have a mechanism to evaluate the quality of a contracted service. Agency registered nurses (RNs) assigned to the emergency department (ED) are not evaluated at specified intervals to ensure patient care is provided in a safe and effective manner.

Findings include:

-- Review of the contract agreement between the staffing agency, Supplemental Health Care and the hospital that commenced on 7/17/07, revealed the hospital is responsible to ensure that services provided comply with all provisions of Federal, State and local statues, rules and regulations. Agency nurses shall perform in such a matter as is reasonable and customary within the profession.

-- Per interview of Staff E (ED Director) on 2/7/17 at 11:50 am, when an agency nurse starts he/she would have a 2 day orientation to the ED. On the first day they take a medication test, EKG rhythm test and point of care testing. They meet with the educator who reviews an orientation packet and are oriented to Meditech (the hospital's electronic medical record). They work with an ED staff RN who signs off their checklist, this may include different RNs as shifts and staffing vary.

-- Review of the personnel file for Staff D, (agency ED RN) on 2/8/17, revealed an "ED Travel RN Competency" checklist initiated on his/her first day of work (6/14/16) to monitor his/her skills through observation, verbalization, simulated return demonstration and written test/self study module by a preceptor. Not all areas were checked off as completed (e.g., location of facility policies and procedures, nursing worklist and expectations of documentation and sepsis pediatric screening). The last entry to the checklist was dated 6/22/16.

-- During interview of Staff D on 2/14/16 at 2:00 pm, he/she revealed that he/she had no formal orientation to triage. Staff D's competency checklist was signed off on 6/14/16 with an S (indicating simulated return demonstration) for the area titled "Triage Process - category/assessment/room placement." Staff D spoke with the nurse manager after the second or third time he/she had been in triage and relayed that he/she was uncomfortable in triage. Staff D was told he/she had experience as a triage nurse and it would be okay. Staff D indicated he/she was put back in triage the day after a patient was found unresponsive in the waiting area.

-- During interview of Staff B (ED RN/Charge Nurse) on 2/10/17 at 1:15 pm, he/she revealed travel RN staff do not receive any formal evaluations of their skill or performance after their initial orientation checklist is completed.

Based on findings from document review and interview, (a) in 2 of 21 medical records (MRs), staff documented patient information into the MR under another staff member's computer log in. (b) A staff member indicated MR entries are "back timed". These practices could lead to MR information not being accurately entered and properly authenticated.

Findings related to (a) include:

-- Per review of Patient #1's MR, Staff B (Emergency Department (ED) Registered Nurse [RN]) documented vital signs, patient assessment and (triage level) on 1/19/17 at 6:15 pm. However, per interview of Staff B on 2/8/17 at 11:15 am, he/she did not document the vital signs, assessment and triage of Patient #1. He/she was not working triage during that time. He/she did not sign off of the computer used in triage earlier in the day, therefore, another nurse documented under his/her name. Staff B stated the computers do not automatically log you off after a certain amount of time. The incoming nurse is suppose to sign in under his/her own name.

-- Per interview of Staff D (ED RN assigned to triage) on 2/14/17 at 2:00 pm, he/she obtained Patient #1's vital signs, assessment and assigned triage level on 1/19/17 at approximately 7:00 pm to 7:15 pm. He/she documented this information in Patient #1 MR on the computer in the triage area. Staff D indicated he/she "backtimed" the entry to 6:00 pm - 6:20 pm, nearer to the time Patient #1 presented to the ED.

-- During interview of Staff F (Vice President) on 2/8/17 at 9:40 am, he/she revealed Staff B was assigned to the triage area earlier in the day and at the end of his/her assigned triage duties (3:00 pm) he/she did not sign off the computer he/she was using. A full audit of computers confirmed documentation in Patient #'1's MR was entered into the computer located behind the triage desk and dated 1/19/17 at 6:15 pm.

-- Review of Patient #2's MR revealed an entry by Staff G (ED RN) dated 1/1/17 at 3:00 pm, that stated "All previous charting on pt (patient) under Staff H (Agency ED RN) was actually Staff G, RN."

-- During interview of Staff E (ED Director) on 2/8/17 at 4:00 pm, he/she acknowledged the above findings.

Findings related to (b) include:

-- Review of the hospital's policy and procedure (P&P) titled "Triage Policy Ver 5," dated 11/19/15, indicated it is the responsibility of the primary nurse in the treatment area to complete and document the "quick" triage assessment within 10 minutes of patient arrival.

-- Review of the hospital's "Emergency Department Travel RN Competency," checklist, undated, indicated under the triage process for quick registration and quick triage that regulatory time door to triage in 10 minutes (walk in and EMS arrivals), to document the triage time accurately - changing time if needed and changing the time in Meditech (the hospital's electronic MR).

-- During interview of Staff D (ED RN assigned to triage) on 2/14/17 at 2:00 pm, he/she revealed he/she obtained Patient #1's vital signs on 1/19/17 at approximately 7:00 pm to 7:15 pm and documented ("back timed") the vital signs in Patient #1's MR in the computer in the triage area at 6:00 pm-6:20 pm, nearer to the time Patient #1 presented to the ED. Staff D stated he/she was trained to document ("back time") the comprehensive assessment to within 10 minutes of the patient's arrival to the ED.

-- During follow up interview of Staff E (ED Director) and Staff J (Risk Manager) on 3/6/17 at 2:05 pm, they revealed the "quick" triage assessment on the "Emergency Department Travel RN Competency," checklist was not worded correctly. It consists of an assessment (eyes on the patient, vital signs and assignment of Emergency Severity Index (ESI)) to determine if the patient can go to the waiting area or needs to immediately be brought into the ED. The comprehensive assessment should be done within 10 minutes of arrival to the ED. Staff has been instructed that the goal is to have patients presenting to the ED be triaged within 10 minutes of arrival. Additionally, nurses are encouraged to actively document when they do something in the electronic MR, however, sometimes there is a lapse in time. For example, a patient presenting to the ED whose vital signs have been obtained and is triaged as a level 2, may be brought right back to the ED and 10 -15 minutes has passed. The nurse will document the vital signs showing the actual time the vital signs were taken. The electronic MR doesn't allow you to "back time" or change the time in the electronic MR.

Patient #1's MR indicated a comprehensive triage assessment with vital signs was entered on 1/19/17 at 6:15 pm. It was not possible to backtime these entries. Staff can add a note indicating they obtained vital signs at a different time but the computer entry time cannot be changed. Staff D indicated he/she obtained Patient #1's vital signs at 7:00 - 7:15 pm.

Based on findings from document review, video review, interview and observation, (a) the hospital failed to provide appropriate care to a adult patient (Patient #1) in the emergency department (ED). (b) In 1 of 1 MRs (Patient #1) reviewed of patients being reassessed/monitored in the waiting area and in 4 of 4 MRs (Patients #3, #4, #5 and #6) reviewed of patients who left without being seen (LWBS), no reassessments of the patients in the waiting area were documented.

Findings regarding (a) include:

-- Review of the hospital's policy and procedure (P&P) titled "Triage Policy Ver 5," dated 11/19/15, indicated the ED RN (registered nurse) will triage each presenting patient to prioritize and optimize ED flow, by assessing, identifying and expediting those patients that require immediate care. If the Registration Clerk is the one to greet the patient a call must be placed to the triage RN immediately. The triage RN will complete a "QuickTriage" assessment of an "eyes on assessment" of the patient and documentation of ... , a full set of vital signs T, P, R (temperature, pulse, respirations), BP (blood pressure) and SPO2 (oxygen saturation) level ... . If it is determined the patient does not need immediate treatment he/she can present to the Registration Clerk to be fully registered. Patients that come in by ambulance can either be placed in an open ED bed or placed in a wheelchair and sent to the triage area for an initial triage assessment as indicated. If no open beds are available, patients with a Emergency Severity Index (ESI) level 3, 4, and 5 can be placed in the waiting area after the initial triage assessment is completed until a treatment space becomes available.

-- Per MR review, Patient #1, a 52-year-old male, presented to the ED on 1/19/17 at 6:09 pm via Emergency Medical Services (EMS). Upon arrival to the ED, Patient #1 was transferred from the stretcher to a wheelchair and placed in the waiting room by EMS. Report and transfer of care was given to the RN in triage. A nurse documented a triage assessment and vital signs (temperature - 98.7 Fahrenheit (F), pulse - 64, respirations -18, blood pressure -122/82) at 6:15 pm. Patient #1 was triaged as a level 4 on the ESI.

Nursing next documented on 1/19/17 at 8:43 pm (2 1/2 hours later) " ... patient came to ED willingly, was in wheelchair in waiting room, speaking with receptionist when he slumped over in wheelchair. Pt (patient) immediately brought to room 14, placed on stretcher and cardiac monitor. Pt had no pulse, entire body mottled, no respirations. CPR (cardiopulmonary resuscitation) was started, ABC (emergency code) alert called, MD (physician) in room immediately. No pulse recovered, no spontaneous respirations, time of death 20:37 (8:37 pm)."

-- On 2/8/17 at 9:40 am, two Department of Health surveyors viewed the hospital's surveillance video files dated 1/19/17 from 6:06 pm - 8:26 pm (approximately 2 hours and 20 minutes). The video files showed Patient #1 entering the hospital through the ED ambulance entrance via stretcher with EMS personnel. (There was a brief time frame, approximately 2 ½ minutes, the patient is not on video as there was no camera in that area.) Per interview of hospital staff Patient #1 was transferred from the EMS stretcher to the wheelchair with assistance from hospital staff. Patient #1 is then seen being wheeled out to the reception window (past the triage area) where the receptionist obtains paperwork and applies a bracelet. Patient #1 is then wheeled into the waiting area by EMS and placed facing the reception window. EMS personnel relayed report to the nurse assigned to triage. The remainder of the video files revealed Patient #1 sitting in the waiting area facing the reception desk. He is seen handling a plastic bag, attempting to stand or adjusting himself in the wheelchair and turning his head. Patient #1's last movement was noted at 6:58 pm.

-- Per interview of Staff B (ED Charge Nurse) on 2/10/17 at 1:15 pm, he/she revealed taking the ambulance call from EMS that they were bringing in Patient #1. He/she mistakenly thought Patient #1 was another patient who frequently is seen in the ED and is disruptive and went to look for a room to put the patient in. When he/she returned to the desk the paramedic informed him/her Patient #1 was out front (the triage area). Staff B never laid eyes on Patient #1.

-- Per interview of Staff I (ED Receptionist) on 2/10/17 at 2:20 pm, Patient #1 arrived to the ED via ambulance on a stretcher. He/she helped Patient #1 from the stretcher to a wheelchair. EMS wheeled Patient #1 to the waiting area facing the reception window. Staff I was with the patient during the 2 1/2 minute time frame where there is no video feed. At approximately 8:15 pm or 8:20 pm, Staff I went to bring another patient from the waiting area into the ED and noticed Patient #1 looked deceased. He/she informed the triage nurse. Staff I stated he/she did not see anyone obtain vital signs or assess Patient #1 when he arrived to the ED or in the waiting area.

-- Per interview of Staff D (ED RN/Triage Nurse) on 2/14/17 at 2:00 pm, he/she received report from EMS regarding Patient #1 but did not see the patient at that time. Staff D indicated he/she triaged the patient and obtained his vital signs at approximately 7:00 pm to 7:15 pm. He/she indicated Patient #1 denied chest pain, dizziness and didn't know why he was at the hospital. Staff D obtained and documented the vital signs and triage but "back timed" the assessment to 6:00 pm - 6:20 pm, nearer to the time Patient #1 presented to the ED. (Staff D stated he/she was trained to "back time" the comprehensive assessment to within 10 minutes of a patient's arrival to the ED.) See related findings in Tag A438.

Although Staff D indicated he/she triaged and assessed Patient #1, this could not be corroborated by video files or other staff interviews.

Findings related to (b) include:

-- Review of the hospital's P&P titled "Triage Policy Ver 5," dated 11/19/15, indicated patients with ESI level 3, 4, and 5 can be placed in the waiting area after the initial triage assessment is completed until a treatment space becomes available. The triage nurse should round in the waiting area hourly to complete vital signs on all waiting patients and assess for any change in the patients' condition.

-- Per review of Patient #1's MR, he presented to the ED on 1/19/17 at 6:09 pm with a chief complaint of failure to thrive. Nursing triaged the patient at 6:15 pm with an ESI level of 4. The next documentation by nursing was at 8:43 pm, (2 1/2 hours later) indicating Patient #1 was found unresponsive.

-- Per review of Patient #3's MR, she presented to the ED on 12/7/16 at 12:02 pm with a chief complaint of knee pain. Nursing triaged the patient at 12:56 pm with an ESI level of 4. The next documentation by nursing was at 9:00 pm (8 hours later) indicating Patient #3 LWBS.

-- Per review of Patient #4's MR, she presented to the ED (sent from Urgent Care) on 10/8/16 at 1:23 pm with a chief complaint of back pain. Nursing triaged the patient at 1:26 pm with an ESI level of 3. An electrocardiogram (EKG) was performed at 1:34 pm, the patient was then placed in the waiting room. The next documentation by nursing is at 4:36 pm (3 hours later) indicating Patient #4 LWBS.

-- The same lack of reassessment documentation was noted for Patient #5 (ESI level of 3 and 4 hours later LWBS) and Patient #6 (ESI level of 4 and 2 1/2 hours later LWBS).

-- Per interview of Staff K (ED RN) on 2/8/17 at 8:30 am, he/she revealed the triage nurse reassesses patients in the waiting area every hour or more frequently if needed.

-- Per interview of Staff D on 2/14/17 at 2:00 pm, he/she reassesses patient's in the ED waiting area by looking at them. He/she assumes the triage RN is to monitor the waiting area in collaboration with the Charge Nurse.

-- Per interview of Staff E (ED Director) on 2/7/17 at 11:50 am and 2:00 pm, the triage nurse is to monitor the waiting area. Also he/she acknowledged the above findings.

Based on findings from document review and interview, the emergency department (ED) policy and procedure (P&P) for EMTALA (Emergency Medical Treatment and Labor Act) lacked a complete description of the hospital's responsibilities and requirements. Staff education regarding EMTALA was incomplete and staff lacked an understanding of EMTALA.

Findings include:

-- Review of the hospital's P&P titled "EMTALA Violations Ver 2," dated 6/2016, revealed it lacked information regarding the hospital's EMTALA responsibilities (i.e., performing an appropriate medical screening exam (MSE), provide necessary stabilizing treatment for an emergency medical condition (EMC), appropriate transfer, no delay in treatment and recipient hospital's requirements).

-- Review of the hospital's Healthstream (computer education program) annual training titled "2017 Regulatory Compliance Course EMTALA," revealed it lacked information regarding recipient hospital responsibilities and the process regarding transferring of patients to another facility (higher level of care).

-- During interview of Staff L (ED Registered Nurse (RN), Agency nurse) on 2/7/17 at 10:45 am, he/she was unsure if the facility had provided EMTALA training.

-- During interview of Staff M (RN who floats to ED) on 2/7/17 at 11:10 am, he/she indicated he/she has not had any training regarding EMTALA.

-- During interview of Staff N (ED RN) on 2/7/17 at 11:40 am, he/she indicated EMTALA involves transfers and bringing people back into the ED. He/she indicated he/she really wasn't sure what else it involved.

-- During interview of Staff E (ED Director) on 2/8/17 at 4:00 pm, he/she acknowledged the above findings.