HospitalInspections.org

Based on records review, observation, and interviews, the facility failed to meet the emergency needs of patients. Due to critical shortage of staff, an individual who presented to the Emegrency Department (ED) had a cardiac arrest in the waiting area while waiting to be triaged/examined and subsequentlty died.


The reception area of the ED is staffed with non-professional individuals. When an individual come to the reception area, the reception staff will take the individual's name, insurance information, and presenting complaint then enter it into the log, and instruct the individual to sit in the waiting area.


Interview with the reception staff on duty on December 12, 2017, informed the surveyors that individuals often tells her that they want to be seen at the Fast Track area, the Urgent Care area, or the main ED. She told the surveyors that any RN assigned as Triage Nurse will come and take the patient for Triage assessment. The timeliness is inconsistent depending if there is an assigned Triage Nurse or not, and the availability of a Triage room. There are only 2 triage rooms where RN's conduct triage on individuals. Individuals are held in these rooms until there is a bed in the ED for them or sent back to the waiting area to wait for examination and/or treatment. As long as individuals are in the triage rooms, no other individuals can be triaged.


Interview with one of the Lead Clinical Nurse in the ED on December 13, 2017, revealed that the Triage area is staffed with an RN from 7:00 AM to 11:00 PM but there is no Triage Nurse assigned after 11:00 PM due to shortage of staff. Triage Nurses do not go to the waiting room to reassess or re-evaluate patients to ensure that the patient condition has not deteriorated or the assigned Emergency Severity Index (ESI) to the patient during Triage has not changed. She stated that due to shortage of staff, patients are waiting 90 minutes or longer to be triaged.


The ED policy indicates under Staffing Patterns:

a. Triage will be staffed with a minimum of one RN at all times (24 hrs /day, 7 days/week).

b. During periods of high census, the triage nurse must notify the ED lead clinical/charge nurse when assistance is needed to meet the goal of triage within 15 minutes.

c. The triage RN should not be assigned to cover for staffing shortages in the ED.

d. RN assignments are listed on the ED nursing assignment sheet.


On October 2, 2017, at 08:31 PM, an ambulatory male patient presented to the ED with complaints of chest pain. The reception staff entered his information on the log and told him to go sit in the waiting area. At 8:49 PM, the Security Officer recognized the individual and went to talk to him and suddenly, the individual lost consciousness. Help was summoned, and the staff from the Main ED responded, found the patient with no pulse or respirations. Cardio-Pulmonary Resuscitation (CPR) was initiated. At 08:54 PM, the patient was transferred via stretcher from the waiting area to the Main ED. Resuscitation efforts continued, finally intubated at 09:31 PM, pulses regained at 9:39 PM. Transfer arrangements were made to Presbyterian Hospital in Albuquerque at 11:08 PM. The individual was placed on an ambulance enroute to the Air Ambulance at the Gallup Airport at 01:10 AM, October 3, 2017. However, the individual went asystole on the ambulance at 01:33 AM and returned the individual back to the hospital. Individual was pronounced dead at 01:38 AM, October 3, 2017, by the ED physician on duty.


Interview with the ED Assistant Supervisor (EDAS) regarding the October 2, 2017, event revealed that she learned about the patient death in the waiting area the following day when she came to work. She brought this up to the Chief Medical Officer (CMO) who told her that there is nothing that needed to be done. She stated that she wanted a Root Cause Analyses (RCA) to be done but was rebuffed, so no RCA was done until The Joint Commission (TJC) came onsite to the hospital in November 2017. The EDAS told surveyors that nothing has changed since the individual's death at the waiting area.


Random observations and informal chats with individuals in the waiting area on December 12 - 13, 2017, revealed that no ED staff checks on the status of those individuals waiting for examination and/or treatment to determine whether their conditions has not deteriorated that requires immediate intervention.


On December 13, 2017, at 09:30 AM, The Acting Quality Manager (AQM) requested to talk to the surveyors to present the results of the RCA completed on the death of the individual in the waiting area. She told the surveyors that no RCA was done until TJC came onsite to the hospital on November 22, 2017. She stated that the RCA result identified several areas for improvement including shortage of staff in the ED. When she was asked to talk about changes made since the death of an individual in the waiting area occurred, she responded that "we are just starting to put plans in place." When she was asked to talk about what actions were put in place to ensure that the condition of individuals waiting for examination in the waiting area has not deteriorated, she responded "the ED staff try to check on them." The surveyor asked if there is a likelihood that an individual waiting for examination in the waiting area could be again found dead while waiting for an examination since no staff are reassessing or re-evaluating the conditions of those individuals. No response.


On December 13, 2017, one of the ED physician called in to speak to the surveyors. She told the surveyors that they have been asking for help from the Executive Leadership Team (ELT) for over a year regarding critical shortage of staff in the ED but nothing happened. The patient who died in the waiting room on October 12, 2017, was waiting to be triaged. Nothing was ever done about it.


On December 13, 2017, at 4:00 PM, the AQM informed the surveyors that a Registered Nurse (RN) has been assigned in the waiting area to reassess the condition of individuals every 15 minutes. On the way out of the hospital at 06:30 PM, the surveyors observed a staff chatting with individuals in the waiting area. The surveyors approached the staff and asked what she was doing. She stated that she works at the Tohatchi Clinic of the hospital and has been reassigned to the ED waiting area to check individuals every 15-minutes to make sure their condition has not changed.


On December 14, 2017, at 10:30 AM, an interview was conducted with the ED Monitoring RN for that shift. During the interview, the RN indicated that he has the guidance of his duties and responsibilities, when he was assigned to monitor individuals in the waiting room. The RN stated that he observed every individual as he or she entered the waiting room. He stated that there are two red buttons in the waiting room. He can activate the button and the ED staff will come immediately. The RN stated that he conducts rounds and documents each individual's status every 15 minutes. He presented a clip board with documents pertaining to the health status of each patient.


On December 14, 2017, at 4:30 PM, an observation was made of the Emergency Room waiting room RN. He was observed talking with individuals in the waiting area waiting for examination and/or treatment, and he was moving around the waiting room.


The CMO was interviewed on December 14, 2017, at 10:00 AM, regarding the patient who died in the waiting area. He told surveyors that he reviewed the medical record but did not think that an RCA was needed but RCA has been done since TJC came to the hospital in November 2017. The CMO was asked to talk about changes that has been made since the event occurred to ensure that no individual will die again while waiting for Triage Assessment or Medical Screening Examination. He stated that nothing has been changed since then "but since we have already completed the RCA, we will be working on the plans to address the identified issues."


Patiemt Safety:

The ED is configured into 3 separate areas with one common area for patient presentation: Main ED, Urgent Care, and Fast Track. The Main ED has 11 beds with one isolation room. The Fast Track area has 5 cubicles. The Urgent Care area has 13 examination rooms.


Interview with staff revealed that the patient call light system went out of commission since 2015, following a renovation done at another area of the hospital. This issue was repeatedly brought up to the attention of the Executive Leadership Team (ELT) and the response was always the same: "you are getting a new ED, so just wait for it." The Joint Commission cited this as part of their "Immediate Threat to Life" survey findings on November 22, 2017 and a "cowbell" was provided to patients until the call light system was brought back online. At the time of the CMS survey on December 12 -14, 2017, the patient call light system at the Main ED was functional but the cords in 2 bed areas are short that the bed has to be positioned in a certain way for the call-light button to reach the patient on a bed.


However, the Fast Track and Urgent Care areas has no working patient call light system.


The two staff members at the Fast Track area told the surveyor that there is no call light system in that area. When questioned as to how they would call in case of a medical emergency, the two staff responded: "We will have to leave the patient and go around and call for help because we don't have a working telephone." The two staff stated that on November 25, 2017, they notified the hospital administration that the telephone was not working. They notified the administration for the second time on November 28, 2017. When asked what was done, the staff indicated that nothing was done.


The Urgent Care area has no working patient call-light system. During the survey, it was confirmed by the Urgent Care staff that there is no call light system for the patients or staff to call for help if help is needed.



Staffing issue:

Based on observation, document reviews, and interviews, the emergency department (ED) failed to have adequate staff to meet the emergency care of individuals presenting for examination and/or treatment, and anticipated needs of the hospital according to the acuity of individuals presenting to the hospital and the volumes of individuals seen.


The ED Spervisory Clinical Nurse (SCN) was interviewed on December 13, 2017. She told surveyors that based on patients' acuity, there should be 36 staff on duty that day but there were only 23 direct patient care staff on duty, of those only 4 were permanent staff. She told surveyors the ED was short 6 staff on December 11, 2017, 8 staff short on December 12, 2017, and 8 staff short on December 13, 2017. She stated that 2-3 staff from other areas of the hospital are pulled per week to work in the ED. The majority of the staff in the ED are contract nurses since many permanent staff have left the hospital. The contract nurses are at the hospital usually on a 13-week assignment. When asked how long this has been going on, she stated "maybe over a year now." When asked what was being done about it, she told surveyors that the ELT has been told repeatedly about it but nothing is being done.

Cross refer to Tag A-112.

Based on observation, document reviews, and interviews, the emergency department (ED) failed to have adequate staff to meet the emergency care of individuals presenting for examination and/or treatment, and anticipated needs of the hospital according to the acuity of individuals presenting to the hospital and the volume of individuals seen.


On October 2, 2017, at 08:31 PM, an ambulatory male patient presented to the ED with complaints of chest pain. The reception staff entered his information on the log and told him to go sit in the waiting area. At 8:49 PM, the Security Officer recognized the individual and went to talk to him and suddenly, the individual lost consciousness. Help was summoned, and the staff from the Main ED responded, found the patient with no pulse or respirations. Cardio-Pulmonary Resuscitation (CPR) was initiated. At 08:54 PM, the patient was transferred via stretcher from the waiting area to the Main ED. Resuscitation efforts continued, finally intubated at 09:31 PM, pulse regained at 9:39 PM. Transfer arrangements were made to Presbyterian Hospital in Albuquerque at 11:08 PM. The individual was placed on an ambulance enroute to the Air Ambulance at the Gallup Airport at 01:10 AM, October 3, 2017. However, the individual went asystole on the ambulance at 01:33 AM and returned the individual back to the hospital. Individual was pronounced dead at 01:38 AM, October 3, 2017, by the ED physician on duty.


The ED Medical Director was interviewed on December 13, 2017. She told the surveyors that she's been asking the Executive Leadership Team (ELT) for help repeatedly to mitigate the critical shortage of staff in the ED for over a year. She stated, the "ED is dangerous for patients, it is not safe, and nobody is listening." She stated that every time she goes to the ELT for help, "they'll ask for me to provide data to support my claim." She provided the data, and the response is always "we'll look at it." The workload data that she provided to the surveyors showed that there were 2759 individuals seen in the ED on October 2017, 2608 on November 2017. The data was delineated into 4-hour sections which showed that the highest volume is seen between the hours of 4:00 PM - 8:00 PM (799 in October and 761 in November). The individual with complaints of chest pain who had a cardiac arrest in the waiting room presented to the ED during one of the busiest times.


The Lead ED Clinical nurse told surveyors on December 13, 2017, that the individual that "coded" in the waiting area on October 12, 2017, was waiting to be triaged but because of shortage of staff, the individual "coded" before someone can get to him. He stated that the Triage area was "backed up that night." He stated that the Triage area is staffed with an RN from 7:00 AM to 11:00 PM but there is no Triage Nurse assigned after 11:00 PM due to shortage of staff. Triage Nurses do not go to the waiting room to reassess or re-evaluate patients to ensure that the patient condition has not deteriorated or the assigned Emergency Severity Index (ESI) to the patient during Triage has not changed. She stated that due to shortage of staff, patients are waiting 90 minutes or longer to be triaged.


The ED policy indicates under Staffing Patterns:

a. Triage will be staffed with a minimum of one RN at all times (24 hrs /day, 7 days/week).

b. During periods of high census, the triage nurse must notify the ED lead clinical/charge nurse when assistance is needed to meet the goal of triage within 15 minutes.

c. The triage RN should not be assigned to cover for staffing shortages in the ED.

d. RN assignments are listed on the ED nursing assignment sheet.


The ED Spervisory Clinical Nurse (SCN) was interviewed on December 13, 2017. She told surveyors that based on patients' acuity, there should be 36 staff on duty that day but there were only 23 direct patient care staff on duty, of those only 4 were permanent staff. She told surveyors the ED was short 6 staff on December 11, 2017, 8 staff short on December 12, 2017, and 8 staff short on December 13, 2017. She stated that 2-3 staff from other areas of the hospital are pulled per week to work in the ED. The majority of the staff in the ED are contract nurses since many permanent staff have left the hospital. The contract nurses are at the hospital usually on a 13-week assignment. When asked how long this has been going on, she stated "maybe over a year now." When asked what was being done about it, she told surveyors that the ELT has been told repeatedly about it but nothing is being done.


Several physicians requested to speak with the surveyors over the 3-day survey. All of the physicians expressed their frustration that the hospital leadership staff don't seem to realize the impact on the critical shortage of staff in the ED which affects other areas of the hospital because staff are being pulled to cover the ED.


An interview was conducted with one of the ED physicians on December 13, 2017, at 11:30 AM. She stated that an RCA was conducted by several ED physicians regarding staffing and patient endangerment, the result was presented to the ELT on October 28. 2016. No action was taken. She stated that she presented data to the ELT and the Medical Executive Committee on September 6, 2017 to plea for the increase in ED staffing. No action was taken except to say "we will look into it." She stated that an individual had a "cardiac arrest/subsequent death" in the waiting area on October 2, 2017, while waiting to be triaged. No change in ED staffing was instituted.


Random observations made on December 12 - 13, 2017, and informal chats with individuals in the waiting area of the ED revealed that no staff assessed/reassessed the condition of those individuals to ensure that no individual has deteriorated and/or required immediate intervention.