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Based on document review, observation and staff interview, it was determined for 1 of 10 (Pt #1) patients who presented to the Emergency Department requiring emergency medical treatment, the Hospital failed to ensure emergency services were provided appropriately. As a result, the Condition of Participation 42 CFR 482.55, Emergency Services, was not met. This has the potential to affect 100% of the patients who utilize the Emergency Department.

Findings include:

1. The Hospital failed to ensure emergency equipment was immediately accessible in the Emergency Department. Please see tag 1103.

2. The Hospital failed to follow policy and ensure an Emergency Severity Index Triage Scale (ESI) was completed on all patients presenting for care through the Emergency Department. Please see tag 1104-A.

3. The Hospital failed to ensure that a patient with a positive sepsis screening was triaged as an ESI 2, and failed to notify the physician immediately, as required by policy. Please see tag 1104-B.

Based on observation and staff interview, it was determined the Hospital failed to ensure emergency equipment was immediately accessible in the Emergency Department. This has the potential to affect 100% of the patients who utilize the Emergency Department with a daily average census of 70 patients.

Findings include:

1. During a tour of the Emergency Department on 3/6/17 at 10:00 AM, oxygen tubing/supplies were in a locked Pyxis medication dispensing machine which requires a code to be entered in order to access the Pyxis' contents.

2. During a staff interview conducted with the Physician Assistant (PA#1) on 3/8/17 at approximately 10:45 AM. PA #1 stated that the registered nurse has access to the Pyxis, "I do not. In the case of an emergency the registered nurse must obtain the oxygen supplies from the Pyxis."

A. Based on document review and interview, it was determined for 1 of 10 (Pt #1) patients, the Hospital failed to follow policy and ensure an Emergency Severity Index Triage Scale (ESI) was completed on all patients presenting for care through the Emergency Department. This has the potential to affect 100% of the patients who utilize the Emergency Department.

Findings include:

1. The Hospital policy titled "Triage Guidelines" (2/22/17) was reviewed on 3/9/17 at approximately 10:00 AM. The policy required "All patients are assessed and categorized using the Emergency Severity Index Triage Scale (ESI Priority Scale). "

2 On 3/6/17 at 10:00 AM, the clinical record of Pt #1 was reviewed. Pt #1 presented to the Emergency Room via Ambulance transport at 6:15 PM and was taken back to room #2. The registered nurse (E #4) documented the triage assessment but lacked the documentation of the ESI Priority Score.

3. On 3/7/17 an interview was conducted with the Director of Clinical Operations (E #1). E #1 reviewed the clinical record of Pt #1 and confirmed the ESI score was not performed. E #1 stated, "an ESI score is to be done on every patient that enters the Emergency Room".

B. Based on document review and interview, it was determined for 1 of 10 (Pt #1) patients, the Hospital failed to ensure that a patient with a positive sepsis screening was triaged as an Emergency Severity Index Triage Scale (ESI) 2, and failed to notify the physician immediately, as required by policy. This has the potential to affect 100% of the patients who utilize the Emergency Department.

Findings include:

1. The education packet titled "Emergency Service RN Clinical Knowledge & Skills Validation Checklist" was reviewed on 3/9/17 at approximately 11:00 AM. The packet requires under "Sepsis Protocol, Assign a triage acuity level of 2 for all patients who meet the triage sepsis screening criteria."

2. The Policy "Standard of Care" was reviewed on 3/06/17. Under "Standard III 1) Nursing personnel involve physicians immediately on ESI Level 1 and 2 patients".

3. On 3/6/17 at 10:00 AM, the clinical record of Pt #1 was reviewed. Pt #1 arrived in the Emergency Department via ambulance transport at 6:15 PM. A Sepsis Screening was conducted during the initial triage assessment at 6:30 PM and was determined positive based on Pt #1's pulse rate of 158 and respiratory rate of 24. Based on the positive sepsis screening, Pt #1 should have been assigned a triage ESI Level 2 which requires immediate physician notification. The clinical record of Pt #1 did not indicate an ESI level 2 or any documentation of physician notification of the ESI level 2. The physician was not involved until 7:10 PM when Pt #1 was coding and CPR (cardiopulmonary resuscitation) started.

4. An interview was conducted with the Director of Clinical Operations (E #1) on 3/9/10 at approximately 11:00 AM. E #1 stated, "The expectation is that staff are to follow the education/training provided. I agree, the ESI score should have been a 2 (two) and the emergency room physician should have been notified immediately."