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Based on interviews and facility document review, the facility failed to have adequate numbers of licensed registered nurses, licensed practical nurses and other clinical personnel to care for and monitor two (2) out of six (6) patients included in the survey sample, as outlined in the facility policy.

The findings include:

On 2/7/23 at 9:00 a.m., a review of six (6) patient medical records was conducted with Staff Member #5 (S5). A review of Patient #5's (P5) medical record revealed that P5 arrived to ED on 1/16/23 at 12:25 a.m. with a complaint of numbness and weakness. P5 was triaged, the assigned night shift nurse completed a rapid initial assessment and P5 was given a triage acuity level of two (2), which means their acuity was emergent. The night shift documented on 1/16/23 severe sepsis screenings at 1:48 a.m., 2:21 a.m., 3:52 a.m., 5:52 a.m., 6:23 a.m. and 7:10 a.m. Vital signs were documented on 1/16/23 at 12:44 a.m., 1:52 a.m., 2:10 a.m., 2:20 a.m., 2:30 a.m., 2:52 a.m. and approximately every ten (10) minutes until 5:20 a.m. The attending physician completed P5's History and Physical exam on 1/16/23 at 4:31 a.m. and P5 was diagnosed with a urinary tract infection (UTI) and sepsis. The attending physician admitted P5 to the Medical Surgical (Med Surg) floor at 4:33 a.m., however, no bed was available in Med Surg floor. P5 was placed in EDIN (Emergency Department inpatient) status - from 1/16/23 at 4:33 a.m. until 1/17/23 at 2:53 p.m. and remained in a bed in the ED until a Med Surg bed became available. During a shift change on 1/16/23 at 7:00 a.m. a day shift nurse was assigned to P5 who documented P5's vital signs every ten (10) to thirty (30) minutes between 7:04 a.m. to 10:00 a.m. and again at 11:12 a.m.. The day shift nurse documented a detailed flow sheet at 11:12 a.m. From 11:12 a.m. to 8:47 p.m., there were no vital signs recorded. The medication administration record revealed that the day shift nurse administered P5's medications at 7:47 a.m., 7:49 a.m., 7:50 a.m., 7:56 a.m., 8:11 a.m. and 8:13 a.m.. A resource nurse assigned to the ED on 1/16/23 documented medication administration at 1:48 p.m. There was no other documentation for 1/16/2023 found in P5's medical record from the day shift nurse or the resource nurse. At 8:00 p.m. on 1/16/23, the night shift nurse documented completion of routine daily care for P5 and the night shift nurse documented P5's vital signs at 8:47 p.m., 9:31 p.m. on 1/16/23, and at 12:33 a.m. and 4:00 a.m. on 1/17/23.

On 2/7/23 the surveyor inquired if P5's monitoring record could be documented somewhere else other than in the Medical record. S4 was unable to find any documentation to support that P5 was monitored or rounded on 1/16/23 between 11:12 a.m. and 8:00 p.m. The surveyor asked why the vitals signs would be recorded every 30 minutes and then were completely absent from medical record between 11:12 a.m. and 8:00 p.m. S4 explained that the dayshift nurse has to actually pull the vital signs into the electronic medical record and it was possible that the nurse was monitoring but just did not document them. S4 also stated that once P5 was EDIN and admitted to the Med Surg floor, that the nursing standards of care for the Med Surg unit were in place. This meant that the Med Surg standards of care were to monitor the vital signs every eight (8) hours. S4 also stated that patients in Med Surg should have been rounded on during those eight (8) hours.

A review of Patient #6 (P6) medical record revealed that P6 arrived to ED on 1/16/23 at 7:09 p.m. by ambulance with complaints of chest pain. P6 was triaged at 7:27 p.m. and determined to be at level two (2) - emergent of the acuity level scale. The night shift nurse documented P6's vital signs at 7:22 p.m., a rapid initial assessment at 7:27 p.m., electrocardiogram (EKG) at 7:31 p.m., a detailed assessment and cardiac related assessment at 10:53 p.m., and a cardiac monitor, physical findings and severe sepsis screening assessment were documented at 10:55 p.m.. The attending physician's History and Physical exam was documented at 9:51 p.m. and P6 was admitted to the Progressive Care Unit (PCU) on 1/16/23 at 9:08 p.m. No bed was available in PCU and patient was placed in EDIN status on 1/16/23 at 9:08 p.m.. An EKG was completed and documented again at 11:10 p.m. The night shift nurse created two (2) ED interdisciplinary notes on 1/17/23, one at 3:01 a.m. and the other at 3:53 a.m. regarding P6's labwork. The next set of vital signs were documented on 1/17/23 at 5:41 a.m. and 6:01 a.m. and then approximately every hour after that. S2 verified that there was no other documentation to support that P6 was monitored or rounded on by ED staff members between 11:10 p.m. on 1/16/23 and 5:41 a.m. on 1/17/23. P6 was transferred from EDIN to PCU on 1/17/23 at 4:55 p.m..

On 2/7/23 at 11:55 a.m., a review of the "Emergency Room hold times" for the dates 1/15/23 through 1/21/23 was conducted. The report calculated the total number of patients who were on hold in EDIN and the total amount of cumulative hours that patients were holding. The report stated:

1/15/23 - Total hold time: 183 hours and 32 minutes
- Total patients: 25 with an average hold time per patient: 7 hours 20 minutes
1/16/23 - Total hold time: 281 hours and 42 minutes
- Total patients: 23 with an average hold time per patient: 12 hours and 14 minutes
1/17/23 - Total hold time: 624 hours and 13 minutes
- Total patients: 40 average hold time per patient: 15 hours and 36 minutes
1/18/23 - Total hold time: 200 hours and 7 minutes
- Total patients: 25 with an average hold time per patient: 8 hours and 0 minutes
1/19/23 - Total hold time: 73 hours 36 minutes
- Total patients: 27 with an average hold time per patient: 2 hours and 43 minutes
1/20/23 - Total hold time: 143 hours and 1 minute
- Total patients: 34 with an average hold time per patient: 4 hours and 12 minutes

On 2/7/23 at 12:35 p.m., an interview was conducted with Staff Member #7 (S7). S7 stated that working in the ED "can be difficult" at times and there are patients on stretchers in hallways and sometimes, patients who should be on telemetry monitors were not. S7 explained that telemetry monitors are located in all of ED rooms and there are about seven (7) portable telemetry monitors that can be used for patients in the hallways. S7 stated that patients are safe. S7 explained that the ED workload is heavy and at times it is hard to get everything done, i.e. a full assessment on a patient. The most patients that S7 has been assigned was eight (8) and this included EDIN patients. During the time of the interview, S7 was assigned seven (7) patients of which three (3) were EDIN patients. S7 explained that "float pool nurse's" maximum nurse to patient ratio was 1:4.

On 2/7/23 at 1:05 p.m., an interview was conducted with S4. S4 stated that they had received staff complaints about the workload and that they have brought in contract labor, hired LPN's, increased the numbers of Patient Care Technicians (PCT) to help and have filled in areas with ancillary staffing. S4 stated that they usually had a full staff by 3:00 p.m. every day with ten (10) RN's and four (4) RN's during the night shift and there were overlaps in staff coverage throughout the entire day.

On 2/7/23 at 1:40 p.m., an interview was conducted with the complainant. The complainant stated that their complaint was "very true", the ED was "extremely unsafe", there were critical patients left in the hallways without being monitored on a telemetry, and there was broken equipment, such as a pulse oximeters, to properly monitor patient's vital signs. The complainant stated that the nurse to patient ratios were "impossible" to provide care for and stated that being assigned more than six (6) patients was too much. The complainant stated that they discussed their complaints with S4 and was told "just do your best". They felt that S4 was dismissive about their complaints and in the future would not want to go to S4 again to discuss their concerns about patient safety. The complainant also explained that many times, patients are pulled out of the rooms and moved to a different location without notifying the assigned nurse. The complainant stated that this affects the continuity of care for patients. The complainant lastly stated that management does not help out on the floor, except for today "because you are here".

On 2/7/23 at 2:00 p.m., a review of the complaint/grievance log was conducted. It was noted that there was a complaint from P5 on 1/18/23. The complaint was made by the spouse of P5 about the lack of quality of care in the ED, the lack of communication about P5 plan of care and that P5's cell phone was missing. The complaint status was closed.

On 2/7/23 at 2:30 p.m., Staff Member #10 (S10) was questioned about P5's complaint. S10 explained that the complaint was made while P5 was still a patient at the hospital and that it was addressed with the patient and spouse, resolved and closed at the time.

On 2/7/23 at 2:35 p.m., an interview was conducted with Staff Members #3, #11 and #12. S3 stated that the facility has had some staffing challenges. They have hired a total of thirty-seven (37) travelers, they have offered higher rates to travelers and increased the nightly shift rates. The hiring team continued to do monthly recruiting events and recently have made job offers to nine (9) applicants with eight (8) having already accepted offers. They have increased the numbers of PCT's on site. S3 stated that they meet on a regular basis with S4 to discuss all ED issues. S3 stated that the ED had nursing support from the team of "float pool" nurses. S3 explained previously the Chief Operating Officer (COO) had direction over the ED, but the direction was given to S3 about a month ago. S3 stated that decision was made to give direction to them because the COO was fairly new in their role at the facility and that S3 had the reputation of "getting things done". S3 was questioned if they were aware that there were patients in the ED that were not being monitored per the standards of care and S3 stated that they just became aware of the situation and that in addition to hiring, they had ordered more stretcher beds and 20 more telemetry boxes. S3 was questioned if they were aware that ED rooms were not getting cleaned between patients. S3 responded that they had just become aware of that issue and met with the Environmental Services staff. S3 explained that Environmental Department was also hiring more staff and in the meantime, they had purchased and placed more Oxivir disinfecting wipes in the ED. S3 was asked how the ED staff would know if the ED rooms had been cleaned, S3 stated that they were discussing a strategy that they could use to indicate that a room was cleaned, such as placing a magnet outside the door to indicate that the room was cleaned.

A review of the facility's policy "Assessment of the Patient" stated in part:
"Emergency Department (ED)...Level 2 - Emergent: Patients who have conditions that may result in loss of life or limb if not treated immediately....Routine Vital Signs: b. Progressive Care Unit i. Vital signs and temperatures to be documented hourly at minimum every 4 hours or more frequently as indicated based on patient condition or as ordered by the provider".

A review of the facility's policy "Assessment and Reassessment of ED Patients" stated in part: "Level 2: Emergent..Vital signs and focused reassessment requirements - minimum hourly, more frequently as condition warrants*".

A review of the daily roster the ED for 1/16/23 revealed that night shift ( 1/16/23 at 7:00 p.m. to 1/17/23 at 7:00 a.m.) provided one (1) Charge Nurse, five (5) RN's, one (1) LPN and two (2) Resource Nurses. The dayshift (1/17/23 at 7:00 a.m. to 7:00 p.m.) provided one (1) Charge Nurse, six (6) RN's, one (1) RN orienting, one (1) LPN and five (5) Resource Nurses.

The above noted findings were discussed with Staff Members #1, 2, 3, 13, 14, 15, 16 and 17 at the exit conference on 2/7/23 at 4:06 p.m.