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Based on observation, interview, and record review, the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice as evidenced by:

1. Failure to integrate with other hospital's departments, services, and resources to ensure the availability of ancillary services in the ED, creating the increased risk of substandard healthcare. Cross reference to A1103.

2. Failure to provide timely MSEs for four of 33 sampled patients (Patients 1, 12, 17 and 33). This resulted in the failure to ensure the patients were assessed in a timely manner to determine if an EMC existed. Cross reference to A1104, example #1.

3. Failure to provide stabilizing treatment by the ED nursing staff for one of 33 sampled patients (Patient 3) for an EMC within the capabilities of the hospital when there was no documentation to show the physician had ordered a sedative medication which was administered to the patient who was documented as unresponsive. In addition, there was no documentation to show the patient's vital signs were monitored for 44 minutes immediately following an episode of very low BP. Cross reference to A1104, example #2.

4. Failure to implement the P&P to obtain a UA for a pediatric patient (Patient 11) with a fever after triage by the RN and there was no documented evidence to show Patient 11 was reassessed one hour after administration of Tylenol and Motrin as per hospital's P&P. Patient 11 left the hospital without being seen by a physician two and a half hours later. Cross reference to A1104, example #3.

5. Failure to implement the hospital's P&P for the aggressive monitoring and assessment for one of 33 sampled patients (Patient 2) who received high risk IV medications. Cross reference to A1104, example #4.

6. Failure of the medical staff to develop policies specific to the use of a PA in the ED.
Cross reference to A1104, example #5.

7. Failure to investigate the unusual events of two Patients (Patients 3 and 17) who were found unresponsive prior to triage. Cross reference to A1104, example #6.

8. Failure to develop a plan to determine the reason the number of patients who left the ED without being seen was increasing. Cross reference to A1104, example #7.

9. Failure to identify the data created by a vendor was correct for the number of discharges recorded and the wide variability in average length of stay in the ED for ED physicians. Cross reference to A1104, example #8.

10. Failure to implement the ED staffing P&Ps and ensure the number of nurses available to care for patients in the ED was appropriate to meet the needs of the patients. Cross reference to A1112, example #1.

11. Failure to have a system in place to address surges in the ED patient census. Cross reference to A1112, example #2.

12. Failure to ensure the competency of one ED RN on a annual basis. Cross reference to A1112, example #3.

The cumulative effect of these problems resulted in the hospital ED's inability to ensure the provision of quality and safe emergency services to patients with potential medical
emergencies.

Based on observation and interview, the hospital failed to integrate with other hospital's departments, services, and resources to ensure the availability of ancillary services in the ED, creating the increased risk of substandard healthcare outcomes to the patients in the hospital.

Findings:

During the observations in the ED on 10/28, 10/29, and 10/30/15, ED nurses were observed drawing blood on patients.

In an interview on 10/28/15 at 0655 hours, RN 16 stated the ED nurses did their own blood draws and respiratory care.

In an interview on 10/29/15 at 0955 hours, RN 14 stated short staffing was an issue; the nurses, not phlebotomists (staff with training in practice of opening veins to remove blood for tests) drew blood and also performed respiratory treatments without the assistance of a RT. RN 14 stated many staff were planned to leave as the job in the hospital's ED was very stressful.

In the interviews on 10/28/15 at 0825 and 0900 hours, RN 1 stated it was difficult to get the nursing staff because the staff were working too hard. RN 1 stated the support staff such as social workers, phlebotomists, and RTs were not available. RN 1 stated a Social Worker or Case Manager was not available to help with social issues such as assistance with homeless patients; the need of help in social work and case management was requested many times but was not provided. RN 1 stated there was no phlebotomist assigned to help in the ED.

Based on interview and record review, the hospital failed to provide emergency medical and nursing services following the P&Ps of the hospital as evidenced by:

1. Failure to provide timely medical screening examinations for four of 33 sampled patients (Patients 1, 12, 17, and 33). This resulted in the failure to ensure the patients were assessed in a timely manner to determine if an EMC existed.

2. Failure to provide stabilizing treatment by the ED nursing staff for one of 33 sampled patients (Patient 3) for an EMC within the capabilities of the hospital when there was no documentation to show the physician ordered a sedative medication which was administered to the patient who was documented as unresponsive. In addition, there was no documentation to show the patient's vital signs were monitored for 44 minutes immediately following an episode of very low blood pressure.

3. Failure to implement the P&P to obtain a UA for a pediatric patient (Patient 11) with a fever after triage by the RN and there was no documented evidence to show Patient 11 was reassessed one hour after the administration of Tylenol and Motrin as per hospital's P&P. Patient 11 left the hospital without being seen by a physician two and a half hours later.

4. Failure to implement the hospital's P&P for the aggressive monitoring and assessment for one of 33 sampled patients (Patient 2) who received high risk IV medications.

5. Failure of the medical staff to develop policies specific to the use of a PA in the ED.

6. Failure to investigate the unusual events of two Patients (Patients 3 and 17) who were found unresponsive prior to triage.

7. Failure to develop a plan to determine the reason the number of patients who left the ED without being seen was increasing.

8. Failure to identify the data created by a vendor was correct for the number of discharges recorded and the wide variability in average length of stay in the ED for ED physicians.

These failures created the potential for the increased risk of substandard healthcare outcomes for the patients in the ED.

Findings:

1. Review of the hospital's P&P titled Emergency Medical Treatment and Active Labor Act (EMTALA) Compliance and Transfer revised 11/13 showed a MSE must be offered to any individual presenting for examination or treatment of a medical condition. The examination must be provided within the capacities of the hospital. The examination must be the same appropriate screening examination that the hospital would perform on any individual with similar signs and symptoms, regardless of the individual's ability to pay for medical care. A MSE is the process required to reach the point at which it can be determined whether an EMC does or does not exist. The triage is not equivalent to a MSE; the triage merely determines the "order" in which patients will be seen, not the presence or absence of an EMC.

Review of the hospital's P&P titled Triage and Treatment of Patients in the ED revised 8/15 showed the hospital shall provide triage treatment to all patients who present to the ED. Triage is a process by which a patient is assessed by the RN to determine the urgency of the problem and appropriate health care resource(s) needed to care for the identified problem.

All ED patients are classified by the triage nurse according to the extent of illness or injury using the Emergency Severity Index (ESI) triage system. The triage nurse has the primary responsibility for assessing and prioritizing patient needs and expediting patient care. The triage nurse shall evaluate each patient upon notification of their arrival. The evaluation includes documentation of: chief complaint, medical information, medications currently being taken, immunization status, allergies, vital signs, physical assessment, and screening for signs of abuse.

Each patient is classified by the triage nurse into one of the following classifications using the ESI:

ESI 1: requires immediate life-saving intervention.
ESI 2: High risk situation or confused/lethargic/disoriented or severe pain/distress.
ESI 3: Vital signs within normal limits. Requires many resources (i.e. labs, electrocardiogram
(EKG), x-ray, IV therapy or intramuscular medications, urinary catheter, laceration repair).
ESI 4: Requires one resource.
ESI 5: Requires no resources (i.e. medication refill, simple wound care, rechecks, splints, oral medication).

The triage nurse shall use professional judgment in the application of the triage guidelines, adhere to the assessment standards established by the ED, and refer patients in immediate danger or in whom there is question as to urgency of their problem to the provider immediately.

For all patients triaged as ESI Levels 1 and 2, the nurse should notify the charge nurse to obtain a bed for immediate treatment and notify the registration personnel.

For all patients triaged as ESI level 3, the nurse should send the patient to the waiting area and instruct them to be seated until their name is called in the event a bed is not immediately available, update the vital signs and assessment on these patients every two hours or more frequently if necessary, and inform the patient to notify staff if they have a change in condition.

Review of the ESI Triage Algorithm of the Triage and Treatment of Patients in the ED showed danger zone vital signs are defined as a HR more than 100 bpm (normal HR is from 60 to 100 bpm), respiratory rate more than 20 breathes per minute, and/or an oxygen saturation (measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen) less than 92%; consider the patient assigned with ESI Level 2 if any vital sign criterion is exceeded.

Review of the hospital's P&P titled Protocol: Emergency Department Treatment and Diagnostic revised 10/13 showed a qualified RN in the ED may initiate the emergency treatment standardized procedures for specific conditions. The RN applies the nursing process to the above factors to determine which, if any, tests should be ordered by the nurse. The RN should assess the patient for pain and notify the ED physician for pain medications as needed prior to diagnostic study as appropriate and initiate order sets at triage in collaboration with the ED physician.

For lower abdominal pain, the protocol showed a order set for CBC (complete blood count is a blood test to measure several components and features in the blood), BMP (basic metabolic Panel is blood test to provide key information regarding fluid and electrolyte status), kidney function, blood sugar levels, UA (urine analysis), and UCG (pregnancy test for females who can menstruate).

Review of the hospital's P&P titled Pain Management revised 9/13 showed the pain intensity will be assessed by using a pain scale consistently according to age and developmental level as appropriate. A pain level between 4 and 6 indicates the patient has moderate pain. A pain level between 7 to 10 indicates the patient has severe pain. Pain management including medications will be provided to the patient by a physician order; when pain is constant, administer the pain medications around the clock as ordered. The goal is to maintain a pain rating of the patient's own comfort level goal. This may be documented with the pain intensity score by indicating the intervention is effective, or by the patient's statement that they do not need treatment for pain.

a. Medical record review for Patient 17 was initiated on 10/29/15. The patient was brought into the ED by a BLS ambulance from a SNF on 10/9/15, due to fever. The time of arrival was documented in the medical record as 1608 hours.

Review of documentation showed soon after arrival into the ED, before the patient was placed in a bed, Patient 17 was noted as pulseless and was not breathing. A Code Blue was called and CPR (cardiopulmonaryresuscitation, a lifesaving technique by forcing air into lungs with chest compression to stimulate breathing and circulation) was immediately started.

Documentation showed Patient 17 was placed in a treatment room at 1608 hours, a breathing tube was inserted into the patient's windpipe and was connected to a mechanical ventilator to help the patient breathe.

Review of the nursing documentation by RN 4 showed the patient was unresponsive upon arrival, pulseless, with no chest rise, and pale. The ED physician was notified and a Code Blue was initiated. However, RN 4's notes were documented at 1552 hours (16 minutes before the arrival time and the time the patient was found unresponsive).

Review of the ambulance run sheet dated 10/9/15, showed the BLS ambulance arrived at the hospital's ED at 1534 hours, not at 1608 hours, and not at 1552 hours, as documented in Patient 17's medical record (34 minutes before the patient was noted as unresponsive).

Documentation by the BLS EMT showed the patient's vital signs were unchanged during the trip to the hospital, at 1515 hours and at 1525 hours. The patient's wheezing and decreased mental status was documented by the BLS EMT as the patient's "norm" per the sending LVN at the SNF. The ambulance run sheet showed the EMT documented "Incident: patient became apneic (not breathing) and pulseless at hospital ER." The documentation showed chest compressions were initiated by the EMT before Patient 17 was placed in an ED bed where ED staff took over the resuscitation.

On 10/29/15 at 1100 hours, in an interview with RN 11 who was present during Patient 17's resuscitation, the RN stated when Patient 17 arrived in the ED, the Charge Nurse (RN 3) did not have time to perform routine responsibilities such as to receive report from the ambulance EMT and assess the patient. RN 4 instructed the EMT to "Hold the wall," without assessing whether the EMT could appropriately monitor Patient 17's condition. RN 11 explained to "hold the wall" was for the EMT to stay and monitor the patient in the hallway of the ambulance entrance until the ED was ready to room the patient. RN 11 further stated the EMT was standing in the hallway beside Patient 17's gurney when one of the ED nurses was passing by and telling the EMT, "Your patient does not look good." Only then the EMT noticed that Patient 17 was pulseless and not breathing. The EMT started the chest compressions and the patient was placed in a treatment room. Resuscitation ensued after.

On 10/29/15 at 1300 hours, the ED patient census and staffing for 10/9/15, was reviewed with RN 11. Documentation showed the ED was saturated with patients at the time of Patient 17's arrival. Five other ambulance patients were waiting for beds in the hallway and 11 patients were registered and waiting to be seen in the lobby. RN 11 stated the ambulance EMTs monitored the ambulance patients in the hallway as there were no additional nurses available in the ED to help out and ease the load.

RN 11 further stated the House RN Supervisor was aware of the situation and instructed the ED staff to prioritize ambulance patients above the patients in the lobby, who were mostly clinic and urgent care type patients only.

RN 11 was asked how the ambulance patients were triaged upon arrival in the ED. RN 11 stated the current practice was for the front lobby triage nurse to focus on the walk-in patients and the Charge Nurse and/or the primary nurse who was assigned to the patient's room would assess ambulance patients.

Review of the ED records showed the first ambulance patient to arrive in the ED on 10/9/15, prior to Patient 17 was classified as an ESI Level 3 and had been in the ED hallway for 48 minutes. The second patient was classified as ESI Level 4 and had been in the ED hallway for an hour and 55 minutes. The third patient was classified as ESI Level 4 and had been in the ED hallway for 53 minutes. The fourth and fifth patients were classified as psychiatric patients but were not yet triaged as there was no ESI level documented for the patients after being in the ED hallway for 20-28 minutes.

On 10/29/15 at 1300 hours, during an interview with the ED Medical Director, he acknowledged the ambulance patients were the hospital's responsibility once the patients entered the hospital ground. The Director also acknowledged a policy was needed to provide direction for triage of ambulance patients.

b. On 11/2/15, medical record review for Patient 33 was initiated. The ED medical record showed Patient 33 presented to the ED (walked in) accompanied by a family member on 7/20/15 at 1220 hours.

Review of the Emergency Department Triage Sign-in form showed Patient 33's check-in time was 1215 hours. The form showed Patient 33 complained of a stomach pain, low back pain, and could not eat or drink.

Review of the ED arrival information showed Patient 33's triage time was at 1306 hours (approximately 50 min after arrival in the ED). Documentation showed the patient's symptoms in the last week were abdominal pain, vomiting, and diarrhea. The abdominal pain assessment showed a reported pain level of 6/10 (moderate) on a pain scale of 0-10 (with 0 = no pain and 10 = worst pain).

The patient reported the acute pain started that morning with aching all over upper abdomen, cramping in right lower abdomen, and lower back pain. Patient 33 was assigned a ESI level 3 (Urgent). Patient 33 went back to the waiting room after the triage. There was no documentation to show any interventions for pain management or diagnostic tests were provided to Patient 33 by the triage nurse.

During an interview and concurrent medical record review with RN 1 on 11/2/15 at 1330 hours, she stated if a patient presented to the ED with symptoms of abdominal pain, there was a protocol that could be implemented immediately, even before the patient was seen by the physician. This would include diagnostic orders including labs as quickly as possible because early detection was important for course of the patients' treatment.

RN 1 reviewed Patient 33's medical record and stated there were no diagnostic orders for laboratory testing or imaging to evaluate the patient's abdominal pain to determine if an EMC existed prior to sending the patient back to the waiting room.

Review of the medical record failed to show documented evidence the triage nurse obtained the patient's vital signs, including pain level and reassessed the patient every two hours after triage.

Review of the Room Call form showed staff called Patient 33 three times and the patient did not answer on 7/20/15 at 1550, 1625, and 1643 hours. Patient 33 was dismissed at 1643 hours.

Further review of the medical records failed to show documented evidence an MSE was performed by the ED physician.

During an interview with Patient 33 on 11/3/15 at 0920 hours, the patient stated she came to the ED with a complaint of abdominal pain, was registered, and waited in the lobby for almost one hour to be called in by the triage nurse. Patient 33 stated when the triage nurse called her, the nurse obtained the vital signs, asked a few questions, put a bracelet with her information on her wrist, and sent her back to the waiting room.

Patient 33 stated the triage nurse told her she needed to wait for a bed; the hospital staff was very busy. The patient stated she waited for almost three hours and then again asked the triage nurse about the waiting time. The triage nurse told her they did not know, so she waited for 30 more minutes. Patient 33 stated no one in the waiting room was called and she could not take it anymore as the abdominal pain became extreme (10/10). Patient 33 stated she decided to leave the hospital and look for another hospital. The patient left the hospital prior to receiving an MSE and had a family member drive her to another general acute care hospital, Hospital B.

During the same interview, Patient 33 further stated she arrived at Hospital B by 1715 hours, and immediately received morphine (narcotic used for pain management) for the abdominal pain, IV fluids for dehydration, and medications for nausea. The patient stated the laboratory tests and diagnostic imaging were done; in about two hours, she was diagnosed with appendicitis (a medical emergency that requires prompt surgery to remove the appendix. If left untreated, an inflamed appendix will eventually burst, or perforate, spilling infectious materials into the abdominal cavity) and was taken to surgery.

Review of the ED Staffing Assignment Log dated 7/20/15, under the miscellaneous section notes showed the ED was down to saturation (overloaded) at 1548 hours, 23 of the 23 beds were filled.

During an interview with RN 14 on 10/29/15 at 1010 hours, she stated the patients in the waiting room left without being medically screened because the hospital did not divert the ambulances runs and the physicians and nurses got too busy.

During an interview with the Medical Director of the ED on 10/29/15 at 1415 hours, he stated approximately 40% of the ED patients came from the SNFs in the area. The Director stated the majority of the patients in the waiting room were all clinically simple patients with clinical symptoms such as earache and could go to the doctor's office, so there was no hurry to see them.

During an interview on 10/30/15 at 1300 hours, RN 3 stated the ED had a hard time with staffing of RNs. RN 3 stated the ED was forced to stay open when saturated because the hospital did not have clear means to divert the ambulance traffic when the ED bays/capacity was full. RN 3 stated the hospital's ED was constantly taking patients, the patients waited in the ED lobby without being seen, and the physicians kept saying the patients in the lobby were just clinic patients (who could be seen in a physician's office). The patients were triaged but eventually left without being seen by a physician.

During an interview with RN 1 on 11/3/15 at 1410 hours, she stated a MSE started when the physician saw the patients in the room. RN 1 stated nurses needed to bring the patients from the waiting room to a bed in order for them to be examined by the physician, administer the medications, and perform the laboratory tests, etc.

c. Review of Patient 1's medical record was initiated on 10/28/15. The patient arrived at the ED on 7/1/15 at 1605 hours, with a chief complaint of chest pain, shortness of breath, and alcohol withdrawal. The patient had a history of hypertension (high BP). The patient left the ED without being seen by a physician on 7/2/15 at 0005 hours, eight hours after arrival to the ED.

Review the Patient Care Timeline dated 7/1/15 at 1605 hours to 7/2/15 at 0005 hours, showed at 1605 hours, Patient 1 arrived at the hospital. At 1608 hours, the patient was assigned an ESI Level 2. The patient's HR was 106 bpm. The patient's BP was 132/62 mmHg. The patient complained of chest pain at a pain level of 5/10.

At 1609 hours, Patient 1 was triaged and an EKG (electrocardiogram, a test that checks for problems rate and rhythm of the heart) was done at 1611 hours.

Review of the EKG report showed the patient's HR was 105 bpm. The EKG was signed as reviewed by the physician; however, there was no date and time documented to show when the physician had reviewed and signed this EKG.

Review of the hospital's P&P showed a patient who was assigned an ESI Level 2 was classified as a high risk situation or a patient who was confused/lethargic/disoriented or in severe pain/distress. For patients triaged as ESI Levels 1 and 2, the nurse should notify the charge nurse to obtain a bed for immediate treatment.

During an interview and concurrent medical record review with the Inpatient Nursing Director on 10/28/15 at 1404 hours, the Director confirmed there was no date and time documented to indicate when the physician had reviewed Patient 1's EKG.

Review the Patient Care Timeline dated from 7/1/15 at 1605 hours to 7/2/15 at 0005 hours, showed at 1643 hours, Patient 1's airway, breathing and circulation were within defined limits. At 1654 hours, the patient was reclassified with an ESI Level 3. However, there was no documented evidence to show the nursing staff reassessed Patient 1's vital signs or pain levels prior to reassigning the patient with an ESI Level 3 on 7/1/15 at 1654 hours.

During an interview and concurrent medical record review with the Inpatient Nursing Director on 10/28/15 at 1404 hours, the Director confirmed the nursing staff had assessed Patient 1's vital signs only twice during the ED stay (on 7/1/15 at 1608 and at 1847 hours).

During an interview with RN 14 on 10/29/15 at 0950 hours, the RN stated an ESI Level 2 would be assigned to a patient who had tachycardia (high HR) and complained of chest pain.

During an interview and concurrent medical record review with RN 1 on 10/29/15 at 1545 hours, RN 1 confirmed Patient 1 was reassigned as an ESI Level 3 on 7/1/15 at 1654 hours. The RN stated the patient's ESI should have been an ESI Level 2, not ESI Level 3 on 7/1/15 at 1654 hours.

Review the Patient Care Timeline dated from 7/1/15 at 1605 hours to 7/2/15 at 0005 hours, showed at 1847 hours, Patient 1's HR remained tachycardic at 110 bpm. The patient's BP was 143/84 mmHg. The patient complained of pain at a level of 5/10. At 2003 hours, the registration of the patient was completed. On 7/2/15 at 0005 hours, the patient was no longer in the lobby and was dismissed.

There was no documented evidence to show Patient 1 was reassessed by nursing for five hours (from 7/1/15 at 1847 hours to 7/2/15 at 0005 hours) as per hospital's P&P.

There was no documented evidence to show the nursing staff communicated with the physician or provided any interventions when Patient 1 complained of chest pain on 7/1/15 at 1608 hours, and complained of pain on 7/1/15 at 1847 hours.

There was no documented evidence to show the physician conducted an MSE for Patient 1 to determine whether an EMC existed prior to the patient leaving the hospital without being seen by the physician on 7/2/15 at 0005 hours.

During an interview with RN 14 on 10/29/15 at 0950 hours, the RN stated a patient would be sent back to the waiting room if there was no open bed in the ED and instructed to inform the triage nurse if their condition worsened. The triage nurse would reassess the patient and if the patient had no further complaints, the triage nurse would reassess the patient every two hours.

During an interview and concurrent medical record review with RN 1 on 10/29/15 at 1545 hours, the RN stated Patient 1 was documented as having left the hospital without being seen by the physician on 7/2/15 at 0005 hours. The RN confirmed Patient 1 was not reassessed for five hours (from 7/1/15 at 1847 hours to 7/2/15 at 0005 hours).


d. Review of Patient 12's medical record was initiated on 10/28/15. The patient arrived to the ED on 5/18/15 at 2208 hours, with a chief complain of pain to the head. The patient had a history of CVA (cerebrovascular accident, or stroke)/TIA (transient ischemic attack or a mini - stroke), and took coumadin (a blood thinner). On 5/19/15 at 0202 hours, the patient left the hospital without being seen by the physician (four hours later).

Review of the Visit Summary Report dated 5/18/15, showed the following:

* At 2208 hours, Patient 12 arrived to the ED.

* At 2214 hours, the patient was triaged. The patient complained of headache at a pain level of 7/10. The patient reported she had hit her head on a hook over the stove at 2000 hours and had a hematoma (bruise).

* At 2220 hours, the patient was sent to the waiting room due to the ED saturation (no open beds).

* At 2232 hours, a CT scan of the head was performed for the patient.

* Four hours later on 5/19/15 at 0202 hours, the patient did not answer when called in lobby.

There was no documented evidence to show the nursing staff communicated with the physician, or provided any interventions when Patient 12 complained of pain at a level of 7/10.

There was no documented evidence to show the nursing staff reassessed the patient's vital signs or pain levels for four hours in the waiting room (from 5/18/15 at 2214 hours to 5/19/15 at 0202 hours).

There was no documented evidence to show the physician examined the patient to determine whether an EMC existed prior to the patient leaving the hospital.

During an interview and concurrent medical record review with the Inpatient Nursing Director on 10/28/15 at 1055 hours, the Director confirmed the above findings.

2. Patient 3's medical record was reviewed on 10/29/15. Documentation showed Patient 3 drove himself to the hospital's ED parking lot on 7/6/15 at 1240 hours. While waiting to be triaged, the patient was found by the triage nurse at 1300 hours, sitting in the wheelchair with head tilted back, being unresponsive, and not breathing. Patient 3 was rushed to a treatment room where resuscitation was begun.

a. Patient 3 was immediately intubated (a breathing tube was inserted to patient's windpipe) and connected to a mechanical ventilator (a machine designed to mechanically move breathable air into and out of the lungs to provide the mechanism of breathing for a patient who is physically unable to breathe, or breathing insufficiently).

Documentation showed at 1305 hours, an IV access needle was inserted and Versed (a potent IV sedation medication) 2 mg was given by RN 5, although Patient 3 remained unresponsive. Further review of the medical record failed to show a documented physician's order to administer Versed.

On 10/29/15 at 1000 hours, RN 11 reviewed Patient 3's medical record and acknowledged there was no written physician's order for Patient 3 to receive Versed.

b. Review of Patient 3's resuscitation's narrative account showed the Code Blue resuscitation was ended at 1313 hours as Patient 3 had an acceptable HR at 111 bpm (normal HR is from 60 to 100 bpm) and BP of 91/59 mmHg (normal is 90/60 to 120/80 mmHg). However, documentation showed Patient 3's BP was very low, 53/38 mmHg at 1352 hours and 52/44 mmHg at 1353 hours.

Despite the patient's very low BP, there was no documentation to show Patient 3's HR and BP were monitored from 1356 to 1440 hours (a total of 44 minutes). Documentation showed during that time, the x-rays of patient's chest and bilateral hip were done followed by an ultrasound of the bilateral legs and a 12 lead electrocardiogram.

Documentation also showed the patient's HR began to decline at 1440 hours. A Dopamine drip (medication to increase HR and BP) was infused intravenously. A Code Blue was called again at 1450 hours. However, at 1528 hours, the Code Blue was terminated and Patient 3 expired.

On 10/29/15 at 1000 hours, RN 11 stated she missed validating the monitored vital signs so the computer did not record the patient's BP and HR in the record.



3. Review of the hospital's P&P Emergency Department Protocol for Treatment and Diagnostics showed for Elevated Temperature in Infants/Children with a temperature greater than 100.4 degrees F, give acetaminophen (Tylenol) 15 to 20 mg/kg suppository per rectum or suspension by mouth (if not given within 4 hours) and Ibuprofen 10 mg/kg, suspension by mouth (if not given within 6 hours). If the core temperature is 104 degrees F or greater notify the ED physician and administer cooling measures. Obtain urine for UA; if unable to obtain within 20 minutes notify the ED physician. Notify the ED physician of any symptomatic febrile patient.

Review of the hospital's P&P titled Antypyretic Medications (medication used to treat fever) reviewed 1/14 showed the following:

* Assess and monitor the patient for side effects of medication, effectiveness of the medication one hour after administration, and need for further medication.

* Further collaborative consultation with the ED Provider shall be done for additional interventions within 15 minutes when the medication is not effective one hour after administration, when the patient experienced recurrent elevations of temperature, and when the patient exhibited side effects of the medication.

Review of Patient 11's medical record was initiated on 10/28/15. The patient arrived to the ED on 5/17/15 at 1903 hours, with a chief complaint of fever. Documentation showed the patient was a pediatric patient who was removed from the patient tracker on 5/17/15 at 2131 hours; the patient left the hospital without being seen by the physician.

Review of the Visit Summary Report dated 5/17/15, showed the following:

* At 1903 hours, Patient 11 arrived to the ED.

* At 1923 hours, the patient was triaged. The patient had fever, chills, weakness, headache, and did not eat all day. The patient's temperature was 103.1 degrees F. The patient reported a pain level of 6/10.

* At 1928 hours, Tylenol (a medication used for fever and pain) was administered to the patient.

* At 1937 hours, Motrin (a medication used for fever and pain) was administered to the patient. The patient was sent to the waiting area due to ED saturation.

* At 2125 hours, the patient was not in the waiting room or in the front lobby when called twice.

There was no documented evidence to show the nursing staff obtained a UA for Patient 11 as per hospital's P&P. There was no documented evidence to show the nursing staff communicated with the physician whether the nursing staff were able to obtain a UA for the pediatric patient as per hospital's P&P for the Emergency Department's Protocol for Treatment and Diagnostics.

There was no documented evidence to show Patient 11 was reassessed one hour after the administration of Tylenol and Motrin as per hospital's P&P.

There was no documented evidence to show the physician examined Patient 11 to determine whether an EMC existed prior to the patient leaving the hospital.

During an interview and concurrent medical record review with the Inpatient Nursing Director on 10/28/15 at 1055 hours, the Director confirmed Patient 11 was not reassessed after Tylenol and Motrin was administered. The Director stated the patient was not in the waiting room when the nursing staff called twice on 5/17/15 at 2125 hours, approximately two and a half hour after arrival to the ED; the patient left without being seen by the physician.

During an interview and concurrent medical record review with RN 1 on 11/3/15 at 1040 hours, the RN was informed and acknowledged a UA was not obtained when the patient's temperature elevated as per hospital's P&P.

4. Review of the hospital's P&P titled IV Medication Administration revised 7/15 showed the following:

* Prior to administration, verify the patient's identification, medication name, dose, route, frequency, rate of administration, and compatibility.

* Aggressive Monitoring is to monitor blood pressure, heart rate, and respiratory rate before injection; at 5, 10, 15, 30, and 60 minutes; then every 1-4 hours per routine.

* B/P monitoring is to monitor the BP before injection; at 15 minutes and 60 minutes after injection; then routine.

Review of the Intravenous Medication Administration Chart of the IV Medication Administration showed the following:

* For the use of midazolam (brand name - Versed, a medication used for sedation) and succinylcholine (a medication causing paralysis of the affected muscle), special consideration and precautions included aggressive monitoring.

* For the use of propofol (an anesthetic) drip, special consideration and precautions included to monitor blood pressure and oxygen saturation (the extent to which hemoglobin is saturated with oxygen. Hemoglobin is an element in the blood that binds with oxygen to carry it through the bloodstream to the organs, tissues, and cells of the body. Oxygen saturation levels, usually measured through pulse oximetry, are normally 95-100%.

Review of Patient 2's medical record was initiated on 10/29/15. The patient arrived to the ED on 7/3/15 at 0445 hours, and expired at 0619 hours.

Review of the Prehospital Care Report dated 7/3/15, showed Patient 2 complained of difficulty breathing. The documentation showed the patient was in severe distress with pale, cool, and moist skin. The patient was unable to speak full sentences. The patient's status decreased while loading into an ambulance. The care of the patient was transferred to the hospital staff by the EMTs at 0446 hours.

Review of Emergency Department Provider Note dated 7/3/15 at 0446 hours, showed Patient 2 had distress and moved all extremities.

Review of the Patient Care Timeline dated 7/3/15, showed the following:

* At 0448 hours, 2 mg midazolam IV was administered to Patient 2 as a verbal order

Based on observation, interview, and record review, the hospital failed to meet the written emergency procedures and needs anticipated by the facility as evidenced by:

1. Failure to implement the ED staffing P&Ps and ensure the number of nurses available to care for the patients in the ED was appropriate to meet the needs of the patients.

2. Failure to have a system in place to address surges in the ED patient census

3. Failure to ensure the competency of one ED RN on a annual basis.

These failures resulted in the potential for patients presenting to the ED to receive substandard healthcare outcomes.

Findings:

1. On 10/29/15, review of the hospital's P&P on Triage Screening of Patients in ED showed its purpose is for the screening RN to complete an abbreviated assessment to help identify the patients that needed to see a provider immediately. All other patients would be fully assessed by the triage nurse when available. Under Procedure #1, it showed the screening RN would be staffed in the ED lobby between the hours of 1100-2300 hours "if staffing allows."

Review of the hospital's P&P on Triage and Treatment of Patients in ED showed the primary responsibility of the triage nurse is to assess and prioritize patient needs and expedite the patient care. The triage nurse should evaluate each patient upon notification of their arrival.

During an interview with RN 1 on 11/3/15 at 1000 hours, she stated for the staffing plan to be adequate to meet the needs of the patients, the following was required:

*At all times - eight RNs (6 RNs, 1 charge nurse and 1 triage nurse, and a nurse in the waiting room). Total is nine, not eight
* From 1100 to 2300 hours - one full-time LVN and one part-time LVN to help the triage RN to obtain the vital signs, conduct the EKG, and draw blood specimens.
* From 0700 to 2300 hours - a RN pre-screener for the patients' waiting room.

The plan showed this staffing would provide coverage for a charge nurse, a triage nurse, and a screener nurse (rapid medical exam) area, and 23 ED beds.

During an interview with the Medical Director of the ED on 11/29/15 at 1315 hours, he stated approximately 40% of the ED patients came from the nursing homes in the area. When the Director was asked about the patients in the ED waiting room, he stated the majority of the patients in the waiting room were all clinically simple patients with symptoms such as an earache and could go to the doctor's office, so there was no hurry to see them. The ED Medical Director stated mistakes could happen due to the lack of an experienced triage RN. He stated the staff were not assigned in the screener nurse role because the hospital was short of ED RNs.

During the observations in the ED waiting room on 10/29/15 at 0915, the lobby included a glass-screened cubicle with a desk. From the cubicle, there was a clear view of the waiting room area. The Admit Clerk sat behind the registration window and the triage nurse worked at a desk in an office that adjoined the waiting room but had a door with a small (approximately 1 square foot) window.

During an interview 10/28/15 at 1400 hours, with RN 1 and RN 2, they stated the RN pre-screener in the waiting room area was intended for rapid evaluation, treatment, and monitoring of patients prior to triage. RN 2 stated sometimes the patients who presented for care in the ED lobby were classified as ESI (ESI is a triage system) Level 3 (urgent) patients. In that case, a workup was started while the patient was waiting to be placed in an ED bed.

RN 2 stated the screener RN was responsible for all the patients in the lobby. RN 2 stated the lobby patients were all at different points in the course of their evaluation or treatment (were triaged, seen by the provider, had labs or x-rays taken, were given medication, or were waiting for discharge information/orders), and required monitoring by the triage/screener nurses. RN 2 stated it was a very busy position; however, RN 2 stated the last time the hospital provided a screening RN in the ED was on 5/4/15 (approximately six months ago).

In an interview with RN 3 on 10/29/15 at 1040 hours, the RN was aware of a policy in development for the position of screening nurse but was unsure if it was put through the approval process. RN 3 stated the position was hardly ever staffed.

In an interview with Admit Clerk 2 on 10/28/15 at 0705 hours, she stated she did not have a medical education but received training to ask a patient if they had chest pain or shortness of breath. For patients with chest pain or shortness of breath, the nurse was paged. When asked her course of action if a patient complained of weakness or jaw pain, she stated she would ask the patient if they had chest pain or shortness of breath and depending on how the patient looked and maybe the nurse could check the patient.

In an interview with RN 13, a triage nurse, she stated the ED got busy at times, and at times she was unable to get help. RN 13 stated the system flagged her if a patient was not seen for 30 minutes. RN 13 stated there were security camera images on a screen to view the waiting room, but that there were some "dead areas" that could not be seen. RN 13 stated she would get stuck in triage and had trouble following up with patients in the waiting room. RN 13 stated the position of the nurse who would monitor the vital signs in the waiting area was not staffed.

In an interview with RN 1 on 10/28/15 at 0825 hours, the RN stated the screener nurse was in the lobby from 1100 to 2300 hours. The RN stated that it was a non-registry RN position, and if in-house staff were not available, the position was not staffed; the triage nurse was expected to pick up the slack.

a. Patient 3's medical record was reviewed on 10/29/15. Patient 3 drove himself to the hospital's ED parking lot on 7/6/15 at 1240 hours. A hospital EMT assisted the patient out of his car to a wheelchair and wheeled him to the registration desk at 1240 hours. After registration, the patient was allowed to remain sitting in the wheelchair by the registration desk. Documentation showed Patient 3 was "initially answering all questions in full and complete sentences." Patient 3 reported hip pain for three days, but he was able to stand on his own.

On 10/28/15 at 0930 hours, in an interview with RN 14, the triage nurse on 7/6/15, she stated the EMT and admitting clerk at the registration desk did not report anything abnormal about the patient. RN 14 stated the ED did not have a screening RN that day to perform the quick patient assessment and or in the last two months due to short staff. When the triage nurse called out for the patient to be triaged around 1255 hours, no one in the waiting area responded so she went around the lobby. RN 14 found Patient 3 unresponsive and not breathing with the head tilted back on the wheelchair. Patient 3 was wheeled to a treatment room where emergency resuscitation began.

In an interview with Security Guard 1 at the adjacent security desk on 10/29/15 at 0915 hours, he stated there was a screening process initiated 3-4 months prior; the glass booth in the waiting area was for that screening nurse, but there was an option for that nurse to be taken away for patient care.

b. Review of the medical record for Patient 33 on 10/28/15, showed the patient presented to the ED on 7/20/15 at 1220 hours, with complaints of having abdominal pain, nausea, and vomiting. The medical record showed the patient was triaged at 1306 hours (50 minutes after arrival in the ED). The screener nurse was not staffed. Patient 33 left the ED at approximately 1600 hours (approximately 3.5 hours after arrival in the ED) without being seen. There was no evidence Patient 33 was ever seen by a provider (physician or PA). Cross reference to A1104, example #1b.

c. Review of Patient 1's medical record was initiated on 10/28/15. The patient arrived to the ED on 7/1/15 at 1605 hours, with a chief complaint of chest pain, shortness of breath, and alcohol withdrawal. The patient had a history of hypertension (high BP). The patient left the ED without being seen by a physician on 7/2/15 at 0005 hours, eight hours after arrival to the ED. Cross reference to A1104, example #1c.

d. Review of Patient 12's medical record was initiated on 10/28/15. The patient arrived to the ED on 5/18/15 at 2208 hours, with a chief complain of pain to the head. The patient had a history of CVA (cerebrovascular accident, or stroke)/TIA (transient ischemic attack or a mini stroke) and took coumadin (a blood thinner). On 5/19/15 at 0202 hours, the patient left the hospital without being seen by the physician (four hours later). Cross reference to A1104, example #1d.

e. Review of Patient 11's medical record was initiated on 10/28/15. The patient arrived to the ED on 5/17/15 at 1903 hours, with a chief complaint of fever. Documentation showed the patient was a pediatric patient who was removed from the patient tracker on 5/17/15 at 2131 hours; the patient left the hospital without being seen by the physician. Cross reference to A1104, example #3.


2. Review of the hospital's P&P titled Scheduling and Staffing revised 3/15 showed for the staffing plan to be adequate, it should be based on census, patient acuity, skill mix, staff competency, and department needs. The section for Staffing Plan showed staffing pattern has been developed to include requirements based on the acuity staffing standards. The staffing pattern determines the number of nursing hours per given workload/census.

In the event of an unforeseen event (short staff, emergencies, etc.) resulting in a short staffing situation, staffing is augmented by appropriately utilizing staff from one unit to another by calling in per-diem, part-time, full-time employees and staff from other corporate facilities. The Charge Nurses are able to take a patient assignment and the Clinical Directors are also available. External agencies nurses are used as a last resort. The ratio compliance for the ED is one nurse (RN or LVN) for four patients. For the ED the following is required:

* ED ratio nurse to patient 1:4 (moderately complex care)
* Triage (RN only) ratio nurse to patient 1:1 (uninterrupted care)
* ICU ratio nurse to patient 1:2 (continuous care).

In an interview with RN 2 on 10/28/15 at 0755 hours, the RN stated the ED was short of two nurses to fill the schedule for 10/27/15.

In an interview with RN 1 on 10/28/15 at 0825 hours, the RN stated when there were holes in the nursing schedule, staff were called and offered overtime and registry staff was called. The RN stated the House Supervisor called for registry staff.

In an interview with RN 13 on 10/28/15 at 0715 hours, she stated open spots in the nurse staffing schedule were previously filled by registry nurses; the ED Charge Nurse was able to book them. RN 13 stated suddenly the ED staff were no longer allowed to call for registry staff; now there was no extra help available.

In an interview with the House Nursing Supervisor on 10/30/15 at 1435 hours, he stated they called nurse registry agencies for nurses but were only able to accept nurses who were trained in the new (implemented in July) electronic health record program used in the ED. The Supervisor stated there were four or five such nurses that they used. The Supervisor further stated the electronic health record training consisted of 6-8 hours of onsite training. When asked, the Supervisor stated he had not documented all efforts to get registry staff.

In an interview with the In patient Nursing Director on 10/30/15 at 1445 hours, she stated the registry nurses were not paid to attend the electronic health record training.


During an interview with RN 3 on 11/30/15 at 1300 hours, he stated the ED had a hard time staffing with RNs. RN 3 stated the ED was forced to stay open when saturated because they did not have clear means to divert the ambulance traffic when they were full. RN 3 stated the hospital's ED was constantly taking patients, the patients waited in the ED lobby without being seen. The patients were triaged but eventually left when not seen by a physician.

The ED Throughput Meeting minutes from 9/29/15 and 10/27/15, were reviewed. The Action/Follow-up column of the minutes for the issue of nurse staffing showed that "house registry still being pursued," and that financial incentives were already in place; however, there was no documentation of any study of the reasons for the difficulty in recruitment and retention of ED nurses, nor any new plan for recruiting and retaining ED nurses.


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On 10/28/15, random review of patient acuity in ED was conducted.

On 8/28/15 at 1923 hours, review of nursing assignment C (Beds 6-9) in the ED showed four patients were assigned to an RN. One of these four patients was a patient waiting for transfer to the ICU, but this was on hold. The additional three patients included a patient with alcohol intoxication, a patient with dehydration who was a possible admit to a medical-surgical floor due to sepsis (infection in the bloodstream), and a patient with hypoglycemic (with low blood sugar).

On the same day and time, nursing assignment B (Beds 2-5) showed four patients in the four beds assigned to another RN. One of the patients had shortness of breath, the second patient had psychiatric issues, the third patient had a substance overdose with a decreased level of consciousness that was waiting for an ICU bed, and the fourth patient with had a laceration with a level of ESI Level 2 (high risk situation or confused/lethargic/disoriented or severe pain/distress).

Review of nursing assignment A on 9/11/15 at 2000 hours, showed the RN had a critical patient with angioedema (rapid swelling of the dermis) who was intubated and required a 1:1 patient to nurse ratio. However, the RN also had two other patients.

Review of nursing assignment A on 10/9/15 at 1935 hours, showed the RN was assigned three patients out of the four beds assigned. The fourth bed was empty and reserved for the emergency resuscitation. Of the RNs' three patients, one had chest pain and would be admitted, the second was on an insulin IV infusion awaiting admission to the ICU, and the third patient had abdominal pain and would be admitted to the hospital due to an infection of the pancreas.

Review of nursing assignment B on 10/10/15 at 1153 hours, showed the RN was assigned for four patients. One of the patients was ICU-bound due to metabolic acidosis (high acid content in blood), the second patient would be admitted due to fever, the third patient was another ICU admit due to chest pain with blood sugar level of 600 mg/dl (normal range: 60-100 mg/dl ), and the fourth patient had headache and high BP.

On the same day at 0300 hours, review of nursing assignment C showed three patients occupied the four beds which was assigned to an RN. One patient arrived via BLS ambulance with a low BP of 70/40 mmHg. The second patient was ICU-bound patient with a low BP and multiple blood transfusions. The third patient had a cough but also had intellectual disabilities who was wandering in hallways and needed a sitter.

On 10/29/15 at 1100 hours, in an interview with RN 11, the RN stated the patient acuity and staffing ratios per the hospital's P&P were not followed by the hospital. The RN stated the staff helped each other, especially on the night shifts with no back-up support even from the House Supervisors. RN 11 stated this could be one of the reasons why the ED nurses quit. Staff could barely take a lunch break with seven nurses, charge nurse, and triage nurse included on the schedule per shift as this left only five nurses to cover 23 beds in the ED. Charge nurses took patient assignments and covered for the newly hired nurses. The RN stated the triage nurses also ended up with patients.

3. An anonymous complaint was previously investigated by the Department in 2015, regarding the hospital's not having a plan in place to call off ambulance diversion due to the ED patient saturation. The hospital's administration's plan of correction was to use the NEDOCS (National Emergency Department Overcrowding Score) system, a scoring tool to determine the ED saturation and guide the ED staff when to call for ambulance diversion.

During the interviews with the ED staff during the survey, the staff stated when the NEDOCS scoring was at red alert at the 200 mark (maximum score) ambulance diversion were not called; the scoring system was ignored by the House Supervisors. The staff stated the decision to call ambulance diversion relied on "the whim of administrative staff that came to the department after the storm was gone."

On 9/29/15, the hospital had a ED throughput meeting to resolve the ED issues in regards to the ED saturation, downtime, and ambulance diversion, and unhappy patients, physicians, and staff. Review of the meeting minutes showed the discussion included the diversion request protocol via chain of command. The ED Charge Nurse and ED physician were to assess the ED situation before notifying the House Supervisor. The House Supervisor was expected to go to the ED, re-assess the situation and maybe resolve the issues. Documentation also showed the "concerns were brought up by the ED Charge nurse that the House Supervisors do not support ED staff when the supervisor's presence was requested."

The meeting minutes failed to show who was to make the final decision for ambulance diversion and whether the House Supervisor still needed to call the CEO or CNO at home for final input. The NEDOCS scoring system which remained a pilot study since July 2015 was not documented as discussed during the meeting. No turn-around time was established for when the House Supervisor should assess the ED situation or when the CEO/CNO should respond.

Review of the second throughput meeting minutes dated 10/27/15, showed the NEDOCS policy status had more revisions based on recommendations from the trial period. The plan now was for the House Supervisors to overstaff inpatient floors to avoid diversion in the ED.

On 10/28/15 at 1400 hours, in an interview with RN 10, he stated the NEDOCS system was adopted from the mother hospital in Northern California since beginning of the year, revised 2-3 times to comply with the ED situation, and implemented in the ED with scores and evaluated for several months now. The system was submitted to the Nursing Department months ago but kept coming back for more revisions. None of the ED staff was told the system was still under pilot study.

On 10/28/15 at 1030 hours, in an interview with RN 3 regarding ambulance diversion, he stated administration would not allow the ED to go down to saturation based on the fact that the inpatient beds were available. The administration did not take into account the NEDOCS score was up to 200 (maximum).

Review of the nurse staffing for 9/21/15 at 1915 hours, listed the Charge Nurse, triage nurse, and four new nurses. There were seven nurses scheduled to cover the 23 ED beds, but three RNs called in sick. The first two RNs listed had less than a year of ED experience, the third RN had two months of ED experience on his own, and the fourth RN was on his first day off orientation. RN 3 stated he was even glad he had an experienced triage nurse that night because the four RNs had no experience on how to defibrillate (shock with electrical current) a patient.

RN 3 stated the Charge nurse was forced to go down on ambulance runs without permission from the hospital administration. However, another hospital staff physician insisted and was able to persuade the ED physicians to accept another ambulance patient "who just needed to be suctioned," despite the ED being closed to ambulance runs. The Charge RN stated this patient arrived via BLS ambulance being "bagged" (artificial respiration to an unconscious patient using Ambu bag) by the EMTs.

During an interview with RN 11 on 11/3/15 at 1100 hours, she stated the ED had a hard time staffing with RNs. RN 11 stated the ED was forced to stay open even when saturated because they did not have clear means to divert the ambulance traffic when they were full or if the ED did not have enough nurses. RN 11 stated the hospital's ED was constantly taking patients, the patients waited in the ED lobby without being seen, and the physicians kept saying the patients in the lobby were just clinic patients (who could be seen in a physician's office).

RN 11 stated administration told them "we need to see the nursing home patients who have insurances; those lobby patients can wait." RN 11 stated the patients in the lobby were triaged but when the ED was saturated the patients sometimes eventually left without being seen by a physician. RN 11 provided, via hospital computer, the hospital's ED rating on patients who left without being seen was 7% while the national benchmark was only 2%.

On 10/30/15 at 1500 hours, during the survey, the hospital administration submitted the policy draft of Full Capacity Protocol/Emergency Diversion as reviewed/signed by the ED Medical Director and forwarded to the Medical Staff committee for approval. The draft was adopted by the Medical Staff and the Governing Body as an official hospital policy on 11/2/15.

Medical record review for Patient 17 was initiated on 10/29/15. The patient was brought into the ED by a BLS ambulance from a SNF on 10/9/15, due to fever.

Review of the documentation showed soon after arrival to the ED, before the patient was placed in a bed, Patient 17 was noted as pulseless and was not breathing.

On 10/29/15 at 1100 hours, in an interview with RN 11 who was present during Patient 17's resuscitation, the RN stated when Patient 17 arrived in the ED, the Charge Nurse (RN 3) did not have time to perform routine responsibilities such as to receive report from the ambulance EMT and assess the patient. RN 4 instructed the EMT to "Hold the wall," without assessing whether the EMT could appropriately monitor Patient 17's condition. RN 11 explained to "hold the wall" was for the EMT to stay and monitor the patient in the hallway of the ambulance entrance until the ED was ready to room the patient.

RN 11 stated the EMT was standing in the hallway beside Patient 17's gurney when one of the ED nurses was passing by and telling the EMT, "Your patient does not look good." Only then the EMT noticed that Patient 17 was pulseless and not breathing. The EMT started the chest compressions and the patient was placed in a treatment room. Resuscitation ensued after. Cross reference to A1104, example #1a.


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4. Review of the hospital's P&P titled Competency Assessment, Employee; Organization-Wide dated 3/15, showed the following:

* Competency assessment is defined as observation and verification of competency.

* Competencies will be identified on an annual basis through a collaborative process, and assessed on a continuum throughout the employment of an individual. This continuum will include assessment during the hire process, initial competencies during orientation period and ongoing annual competency assessment.

* The assessment and/or competency will include initial competency assessment validation of core job junctions, frequently used functions and accountabilities, and high risk job functions and accountability.

* The mechanism for assuring ongoing competence for direct patient care staff includes verification of competency in skills specific to assignment. Verification may be accomplished by direct observation, documentation of mandatory training, documentation of critical incidents, quality assurance monitors, skills lab, or other processes provide information related to staff competence.

An interview and concurrent review of RN 5's personnel file was conducted with the Human Resource Staff on 10/30/15 at 1255 hours.

Review of the Critical Elements Emergency Department, Competency Checklist: Moderate Sedation, and Competency Checklist: Procedural Sedation showed RN 5 was evaluated on 9/9/14 and 10/29/15.

The Critical Element Emergency Department showed RN 5 demonstrated knowledge of critical care medications. The method for evaluation was documented as "V" or verbal.

The Human Resource Staff confirmed RN 5 was not evaluated annually as per hospital's P&P.