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Based on interview and record review it was determined that the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice. Specifically, for 5 of 10 sampled patients the hospital did not ensure patient reassessments, including pain reassessments were documented, and that medication reconciliations were completed or lists of home medications were obtained. (Patient Identifiers: 1, 3, 5, 6, and 7.)

Findings include:

1. Patient 6 sought treatment in the emergency department (ED) on 4/21/2020 at 6:00 AM, for dizziness and multiple falls related to the dizziness.

On 8/4/2020 at 12:13 PM, a telephone interview was conducted with patient 6. Patient 6 stated she did not receive appropriate care at Lakeview Hospital. Patient 6 stated she had experienced, "a lot of pain" while at Lakeview Hospital and that her pain was not controlled while in the ED, and she was discharged to a local skilled nursing facility in pain. Patient 6 further stated Lakeview Hospital did not appropriately reconcile her medications which caused the skilled nursing facility to receive an incorrect medication list and to give her incorrect medications. Patient 6 further stated she was, "put in the back room," and did not receive assistance when needed, including meals while at Lakeview Hospital.

A review of patient 6's medical record was completed on 8/5/2020.

a. Nursing documentation revealed that Hydromorphone (an opioid given for severe pain) 0.5 milligrams (mg) was given intravenously at 7:30 AM, due to a headache with a pain rating of 8 out of 10.

No follow up documentation from nursing staff could be found to indicate the effectiveness of the administered pain medication was assessed.

A physical therapy (PT) evaluation was completed on 4/21/2020 from 8:57 AM to 9:27 AM. The PT documented that patient 6 had a pain score of 5 out of 10 in her neck, left shoulder, and right eye. The PT also documented that medication was an "alleviating factor."

An occupational therapy (OT) evaluation was completed on 4/21/2020 from 10:35 AM to 10:55 AM. The OT documented that patient 6 had a pain score of 4 out of 10 in her head.

Nursing documentation revealed that Ibuprofen 600 mg was given by mouth at 12:30 PM, due to a pain rating of 7 out of 10.

No follow up documentation from any ED staff could be found to indicate the effectiveness of the administered pain medication.

b. Patient 6 discharged from the ED on 4/21/2020 at 6:10 PM to a local skilled nursing facility. No reassessment of any kind was documented after 12:30 PM by the nursing staff prior to patient 6's discharge. Due to the lack of documentation between 12:30 PM and 6:10 PM on 4/21/2020 the survey team could not determine if patient 6's needs were adequately addressed by hospital staff.

Note: The physician documented patient 6 discharged on 4/21/2020 at 3:55 PM. On 8/4/2020 at 3:22 PM, the director of quality (DoQ) confirmed patient 6 did not discharge from the ED until 6:10 PM.

The hospital's "Documenting the Provision of Care" policy was reviewed and revealed the following information:

" REASSESSMENT FOLLOWING MSE (medical screening exam):

...Level (2)/ Emergent will be documented at a minimum of hourly and more frequently if condition warrants.
Level (3)/Urgent will be performed and documented every 2-4 hours as condition dictates ..."

Note: Nursing documentation indicated patient 6 was a "Priority: 3" and should have had reassessments performed and documented every 2 to 4 hours.

On 8/4/2020 at 3:22 PM, the director of quality (DoQ) confirmed patient 6 did not have any reassessments after 12:30 PM on 4/21/2020, or follow up to pain medication administration documented in her medical record.

c. Patient 6 called in a grievance to the hospital on 4/29/2020 relating to the lack of care she felt she received at the hospital. A letter was sent to patient 6 on 5/1/2020 with the following documented, "...Your medical records were reviewed and the staff involved in your care were interviewed. In evaluating your case, it became evident that a breakdown in communication did occur that resulted in a less than complete medication reconciliation. The care provided during your stay looked to be appropriate and necessary...Please know that your concerns have been addressed with our staff and that as a result of your experience we will be modifying our standard med rec (reconciliation) process in the ED..."

On 8/4/2020 at 10:34 AM, a telephone interview was conducted with the DoQ. The DoQ stated a previous employee completed the investigation called in by patient 6, but that she would speak to it the best she could. The DoQ stated ED nursing staff were supposed to complete a medication reconciliation prior to a patient being transferred from the ED to a skilled nursing facility or to the hospital floor. The DoQ stated a medication reconciliation had not been documented by nursing staff for patient 6. The DoQ stated the ED manager had re-educated ED staff during their "huddles" but that they did not keep specific documentation on what was discussed in the "huddles." The DoQ stated she would follow up with ED staff to see if any of them could remember this patient and could talk to the surveyor about patient 6 stay in the ED on 4/21/2020.

On 8/4/2020 at 3:55 PM, the DoQ indicated that after speaking with the ED director and staff that none remembered patient 6 and would not able to answer the survey team's questions about her stay.


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2. A review of patient 3's medical record conducted on 8/4/2020, revealed the following:

Patient 3 was admitted to the ED on 8/3/2020 at 7:39 AM. She voluntarily went to the ED with symptoms of dizziness and weakness. It was documented that she reported these symptoms had been occurring for the last 2 days. She later admitted to taking about 10 pills that belonged to her mother with the intent to fall asleep and not wake up. It was documented that she did not know what kind of pills they were but thought they were muscle relaxers.
a. At 8:00 AM, suicide precautions were implemented which included a reassessment of the patient every fifteen minutes to assess for safety.

Fifteen minute checks were documented in her medical record from 8:00 AM through 11:15 AM. The patient remained in the ED until 2:21 PM, at which time she was transferred to the behavioral health unit for inpatient care related to suicidal intent.

There was no documented evidence that the fifteen minute checks had been discontinued by the physician or that the checks had been conducted between the hours of 11:30 AM and 2:21 PM when she was transferred out of the ED.

b. In a psychiatric evaluation note dated 8/3/2020 at 9:41 AM, it was documented that the patient had been prescribed antidepressant medications two years prior, but had stopped taking them due to the side effects.

In a document titled Certificate for Emergency Commitment it was documented by a physician, "Stopped medications" and "Overdose attempt".

There was no documented evidence in the medical record that the ED staff had completed a medication reconciliation or assessment of home medications the patient may have been taking.

3. A review of patient 7's medical record conducted on 8/4/2020, revealed the following:

Patient 7 was admitted to the ED on 4/25/2020 at 5:19 PM. She was transferred via ambulance from a skilled nursing facility where she was recovering from abdominal surgery. It was documented the patient had a tumor removed from her abdomen in "early April". The exact date of surgery was not documented in her medical record.

a. Upon admit it was documented that the patient reported she did not have any pain. In an initial physician note dated 4/25/2020 at 5:23 PM, it was documented that the patient denied abdominal pain.

In a re-evaluation physician note dated 4/25/2020, (the note was not timed), it was documented that the physician, "was able to express a fair amount of purulence with minimal pressure." There was no documentation as to how the patient tolerated the procedure. Furthermore, there was no documented pain assessment conducted after the procedure or for the remainder of her stay in the ED.

b. In a physician note dated 4/25/2020 at 5:23 PM, it was documented the patient was being treated for a urinary tract infection with Cipro and Macrobid (antibiotics). There was no other documentation about these medications, including dosage, frequency, or duration. Furthermore, there was no documented evidence in the medical record that the ED staff had completed a medication reconciliation or assessment of home medications the patient may have been taking.


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4. Patient 1 was admitted to the facility's ED on 8/3/2020, with a diagnosis of right arm laceration.

On 8/3/2020, patient 1's medical record was reviewed and revealed the following:

a. On 8/3/2020 at 8:30 AM, the nurse performed an assessment and documented a pain scale of 5 out 10. No treatments were documented to address the patient's pain. There was also no reassessment of the patient's pain before discharge.

b. Patient 1's medical record also revealed no documentation of home medications.

On 8/3/2020 at 9:30 AM, the patient was given 500 milligrams of the antibiotic Cephalexin. Because the patient's home medications were not documented there is no way of knowing whether there was a potential drug interaction with the antibiotic and the medications the patient may be on.


5. Patient 5 was admitted to the facility's ED on 5/8/2020, with the primary diagnosis listed as headache. Secondary diagnoses were unspecified fall, striking against or struck by other objects, and laceration without foreign body to scalp.

Patient 5's medical record was reviewed on 8/4/2020, and revealed the following:

a. On 5/8/2020 at 1:14 PM, the nurse performed an assessment of the patient's pain. The patient rated her pain an 8 out 10. No treatments were documented to address the patient's head pain. There was also no reassessment of the patient's pain before discharge.

On 8/4/2020 at 1:42 PM, the facility's DoQ was interviewed. She was asked whether patient 5 should have been reassessed for pain. She stated that the patient's pain should have been reassessed before the patient was discharged, and that it looked like the, "bare minimum" was charted on that patient.

On 8/5/2020 at 1:21 PM, an interview was conducted with patient 5. She stated that when she was at Lakeview ED, on a scale of 1 to 10, her pain was a 9 and that they had not addressed her pain. She stated that when she discharged she was in the same amount of pain.

b. Patient 5's medical record also revealed no documentation of the patient's home medication.

On 8/4/2020, the facility's policy labeled "Documenting the Provisions of Care" was reviewed. Under the ED section it was documented that a detailed assessment should include medications and treatments prior to arrival.

On 8/4/2020 at 1:42 PM, an interview was conducted with the DoQ. She stated that a detailed assessment should be done on every patient, and the physician should have documented on their assessment the patient's home medications as well.