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Based on observation and interview, the facility failed to ensure a sanitary environment for patients by maintaining a clean suctioning system in the emergency room, maintaining a system to prevent urinals from being placed on bedside tables and maintaining a system to ensure the return air vent covers were clean. This affected the patients in the emergency department and on the fourth floor. The census at the time of the survey was 84 patients.

Findings:

On 02/26/13 at 10:30 A.M. a tour of emergency department was conducted with the infection control coordinator and the emergency department nurse manger. During the tour the suction system was observed. The container that housed the collection container was observed to have white, opaque staining in rooms two, four, and the trauma room. During the tour, in an interview the emergency department nurse manager explained the container that housed the collection container was reused from patient to patient. That outer container did not hold body fluids, but did have measuring marks. The inner container did not have measuring marks. During the tour, in an interview the infectious disease coordinator confirmed the white opaque staining on the outer container in the aforementioned rooms. The coordinator did not know what the stains were.

During the tour of the fourth floor on 02/26/13 at 1:00 P.M., Patient #10 was observed in his bed with his urinal placed on the bedside table, this table is used for patient meal trays. The urinal was also observed to be sitting directly on the table without any form of barrier between it and the table.The fourth floor nurse manager stated the urinal was on his table because he/she did not want it on his bed side rail for fear he/she would spill it.

On 02/26/13 at 2:30 P.M. in an interview the infectious disease coordinator stated there were alternatives to leaving the urinal on the bedside table. She said there was a notch on the side rail where the urinal could be placed and face outside the bed and not toward the inside of the bed. Failing that, she said toileting every hour would be preferable. The clinical record review of Patient #10 was completed on 02/26/13. The creview revealed the 97-year-old patient was admitted through the emergency department on 02/23/13 with a diagnosis of lower GI bleed. Review of the nursing care plans did not show any plan related to toileting in general, or, specifically, to offer the urinal every hour rather than keeping it on the bedside table. On 02/26/13 at 1:00 P.M. the fourth floor nurse manager in an interview confirmed the patient's care planning did not include toileting or offering the patient the urinal every hour in lieu of keeping it on the bedside table.

On 02/26/13 at 1:00 P.M. an unannounced tour was conducted of the nursing units on the fourth floor with Environmental Services Manager #1. Rooms 410, 427, 430, 431, and 432 each had return air vents with small clumps of dust collecting in the square spaces of the return air grill. The Environmental Services Manager #1 confirmed the observation in interview during the tour.

Based on interview, clinical record review, and policy review, the facility failed to ensure integration of nursing and medical services in the provision of emergency services. The attending physician failed to confirm agreement with the physician assistant or nurse practitioner's assessment findings , failed to ensure nursing assessments between traige and discharge occurred for patients presenting with hallucinations and failed to ensure the disposition was correct that listed the patient as a transfer to a psych unit by one physician and discharged to home by another physician. The cumulative effect of these systemic problems resulted in the facility's inability to ensure that the patient's emergency needs would be met. This affected Patient #1, #2, #5, #6, and #7. The sample size was 10 patients and the total census was 84 patients.

Findings:

See A1103

Based on interview, policy review, and clinical record review, the hospital failed to ensure integration of nursing and medical services in the provision of emergency services. This affected Patient #2, #5 and #6 who were assessed by either a physician assistant or nurse practitioner and the attending physician did not document he/she agreed with the physician assistant or nurse practitioner's findings. The facility failed to ensure Patient #1, #6, and #7 who presented to the emergency department with hallucinations were assessed by nursing prior to discharge. The facility failed to ensure Patient #1's application for emergency (involuntary) admission was rescinded after assessed by Physician A and ordered to transfer to psych unit, however was discharged home by Physician B who did not sign the discharge order. The total census of the facility was 84 patients and the sample size was 10 patients.

Findings:

The clinical record review for Patient #2 was completed on 02/27/13. The patient was evaluated in the emergency department on 01/18/13 with a diagnosis of back pain. On 01/18/13, a social service consult was ordered for crisis intervention of suicidal thoughts. On 01/18/13 at 10:36 AM, a licensed social worker (Staff D) documented the patient had current suicidal thoughts and a current suicide plan. A physician assistant (PA) assessed the patient and documented his/her findings on the Emergency Physician Record at 09:20 AM, on 01/18/13. A physician, Staff C, signed the Emergency Physician Record at 7:07 PM, but did not mark he/she agreed with the assessment and care plan or confirm the diagnosis. Patient #2 was discharged to a behavioral health center on 01/19/12.
Staff B was interviewed on 02/27/13. Staff B stated he /she was not certain if the physician (Staff C) had evaluated the patient due to the box on the Emergency Physician Record was not marked to affirm the physician was in agreement with the physician assistant's assessment and findings.


The clinical record review for Patient #5 was completed on 02/27/13. The 19 year old patient presented to the emergency department on 01/08/13 at 1:23 A.M. The emergency physician record dated 01/08/13 at 1:30 A.M. stated the patient's chief complaint was suicidal thoughts. A nursing note dated 01/08/13 at 2:36 P.M. stated the patient told the girlfriend he/she was going to take sleeping pills because the patient couldn't see the girlfriend any more. A nursing note dated 01/08/13 at 5:05 A.M. stated the patient was discharged to home with the patient's mother. The emergency physician record was signed by a physician's assistant or nurse practitioner and the physician. However, the physician did not mark whether he/she agreed with the assessment and care plan of the nurse practitioner or physician assistant.

The clinical record review for Patient #6 was completed on 02/27/13. The clinical record review revealed the 21-year-old patient presented to the emergency department on 02/17/13 at 12:40 P.M. with a chief complaint of hearing voices after he/she had been baptized. An emergency physician record dated 02/17/13 at 12:50 P.M. stated Patient #6 denied being suicidal but was maybe going to hurt some children. The behavioral health assessment dated 02/17/13 at 12:57 P.M. stated after babtism the patient heard the devil tell him/her he/she made the wrong decision. The patient was discharged on 02/18/13 at 12:19 A.M. The clinical record did not reveal during the patient's nearly 12 hour stay nursing reassessed him/her for hallucinations or other psychological symptoms. The emergency physician record was signed by a nurse practitioner on 02/17/13 at 8:16 P.M. and the physician, whose signature was not timed. The physician did not mark whether he/she agreed with the assessment and care plan of nurse practitioner.

The Medical Staff Bylaws were reviewed on 02/27/13. The bylaws stated in the emergency setting, all patients following triage, will undergo an appropriate medical screening exam and be offered stabilizing treatment either by the ED physician or an attending physician that is a qualified member of the medical staff.


The clinical record review for Patient #7 was completed on 02/27/13. The clinical record review revealed a triage note dated 02/25/13 at 7:05 P.M. that stated the patient's chief complaint was that the patient was fighting with her/his mother and the patient wanted to kill self by slicing throat. The clinical record review revealed a crisis assessment dated 02/25/13 at 8:15 P.M. that stated the patient was having auditory and visual hallucinations of ghosts telling the patient they are going to kill the patient and that the patient became possessed by demons that make the patient say things the patient doesn't want to say. The patient was discharged to a psychiatric facility on 02/26/13 at 2:40 A.M. The clinical record review did not reveal any nursing assessment after triage to determine whether the patient continued to hear voices or see ghosts during the patients nearly seven hour stay in the emergency department. The Assessment and Reassessment of Patients policy states the registered nurse will perform an assessment throughout the patient stay.

The clinical record review for Patient #1 was completed on 02/27/13. The 28-year-old patient presented to the emergency department on 02/25/13 at 2:34 P.M. with a chief complaint of suicide ideation. The triage nursing note dated 02/25/13 at 2:45 P.M. stated the patient had a suicide plan , was depressed, and an application for emergency (involuntary) admission was completed. The application for emergency (involuntary) admission dated 02/25/13 revealed Patient #1 reported hearing the voice of deceased uncle telling the patient to kill self. The patient stated that deceased uncle molested her when 10 years old and she believes the deceased uncle will hurt her.

The emergency physician record dated 02/25/13 at 2:47 P.M. stated the patient had been having auditory hallucinations "for a while", but was worse that weekend. The physician's order sheet dated 02/25/13 at 4:50 P.M. stated the patient was medically clear for a psychiatric evaluation. A nursing note dated 02/25/13 at 8:29 P.M. stated the patient tried to run when doors near her room opened. The clinical record review does not reveal a clinician's assessment for hallucinations, generalized anxiety, or other reasons to determine the reason for the attempt to elope. The record revealed a physician's order dated 02/25/13 at 8:20 P.M. for medication that read 20 milligrams of Geodon (a medication used for the treatment of depression).

The disposition was listed as a transfer to a psych unit, stable, at 5:10 P.M. on 02/25/13. The disposition was signed by a physician assistant. Physician A marks the box "I agree with the assessment and care plan, and confirm the diagnosis(es) above" and signs. The physician order sheet signed by Physician A has "transferred to" circled (does not say where). The physician order sheet also had "d/c" written on it. The emergency physician record listed the patient's clinical impression as bipolar disorder and schizophrenia.

The clinical record review did not reveal where the application for emergency (involuntary) admission was rescinded. On 02/26/13 at 4:00 P.M. in an interview, Physician B stated he/she let the patient go home and wrote "d/c" in the chart. Physician B stated he/she never signed his/her name to the chart. Although Physician B said he/she never examined the patient, he/she was okay with letting the patient go home. Physician B said the patient was allowed to go home based on the social worker's assessment. Although Physician B said he/she relieved Physician A , there isn't any indication in the patient's clinical record to support this.

The clinical record review revealed a face to face crisis assessment note dated (no time) 02/25/13 by a social worker. The note stated the patient had auditory hallucinations commanding the patient to harm herself. The note stated he/she has had some decrease in symptoms since arriving at emergency department because he/she feels he/she is safer there. Review of the crisis assessment note dated 02/25/13 at 5:25 P.M. stated, "Parents say the voices have not subsided since 2-23-13. No precipitating events. "

The crisis assessment note dated 02/26/13 at 9:30 A.M. stated the patient denied any hallucinations, and felt safe to return home, and follow up with outpatient psychiatric care. Review revealed an untimed crisis assessment note dated 02/26/13 that stated the patient will often hear voices at home but not elsewhere. Review revealed a nursing note that stated the patient went home with her/his parent, signed and dated on 02/26/13 at 10:50 A.M. The clinical record review did not reveal any other time where, since triage at 2/25/13 at 2:34 P.M., nursing staff assessed the patient for auditory or visual hallucinations or suicidal ideation.

On 02/26/13 3:30 P.M. in an interview, the emergency department (ED) nurse manager stated the patient did go home. The ED manager was unable to locate in the clinical record where nursing assessed the patient for hallucinations or suicide ideation when the patient tried to elope on 02/25/13 at 8:29 P.M. or at any time other than at triage, nearly 20 hours prior to discharge.

On 02/26/13 at 4:00 P.M. in an interview, Social Worker #1 said it was safe for the patient to go home, even though that was where the patient has auditory hallucinations the most (and where the balcony is), because that was not something new-it was baseline.

Although the physician's emergency department note dated 02/25/13 at 7:15 P.M. stated, "patient will require further inpatient evaluation" and "transfer and placement pending final bed availability," the physician order sheet did not have a date or time of discharge, nor did it contain an actual order to discharge the patient.

Review of the facility's policy, "Assessment and Reassessment of Patients," approved on 02/06, was completed on 02/27/13. The review revealed the registered nurse will perform an assessment of the patient throughout the patient stay.

On 02/27/13, Quality Manager #1 in an interview confirmed the box stating the physician agreed with the assessment and plan of care for Patient #5 and #6 was not marked, and did not dispute the lack of nursing assessments between triage and discharge for Patient #1, #6, and #7.

Based on interview, policy review, and clinical record review, the hospital failed to ensure integration of nursing and medical services in the provision of emergency services. This affected Patient #2, #5 and #6 who were assessed by either a physician assistant or nurse practitioner and the attending physician did not document he/she agreed with the physician assistant or nurse practitioner's findings. The facility failed to ensure Patient #1, #6, and #7 who presented to the emergency department with hallucinations were assessed by nursing prior to discharge. The facility failed to ensure Patient #1's application for emergency (involuntary) admission was rescinded after assessed by Physician A and ordered to transfer to psych unit, however was discharged home by Physician B who did not sign the discharge order. The total census of the facility was 84 patients and the sample size was 10 patients.

Findings:

The clinical record review for Patient #2 was completed on 02/27/13. The patient was evaluated in the emergency department on 01/18/13 with a diagnosis of back pain. On 01/18/13, a social service consult was ordered for crisis intervention of suicidal thoughts. On 01/18/13 at 10:36 AM, a licensed social worker (Staff D) documented the patient had current suicidal thoughts and a current suicide plan. A physician assistant (PA) assessed the patient and documented his/her findings on the Emergency Physician Record at 09:20 AM, on 01/18/13. A physician, Staff C, signed the Emergency Physician Record at 7:07 PM, but did not mark he/she agreed with the assessment and care plan or confirm the diagnosis. Patient #2 was discharged to a behavioral health center on 01/19/12.
Staff B was interviewed on 02/27/13. Staff B stated he /she was not certain if the physician (Staff C) had evaluated the patient due to the box on the Emergency Physician Record was not marked to affirm the physician was in agreement with the physician assistant's assessment and findings.


The clinical record review for Patient #5 was completed on 02/27/13. The 19 year old patient presented to the emergency department on 01/08/13 at 1:23 A.M. The emergency physician record dated 01/08/13 at 1:30 A.M. stated the patient's chief complaint was suicidal thoughts. A nursing note dated 01/08/13 at 2:36 P.M. stated the patient told the girlfriend he/she was going to take sleeping pills because the patient couldn't see the girlfriend any more. A nursing note dated 01/08/13 at 5:05 A.M. stated the patient was discharged to home with the patient's mother. The emergency physician record was signed by a physician's assistant or nurse practitioner and the physician. However, the physician did not mark whether he/she agreed with the assessment and care plan of the nurse practitioner or physician assistant.

The clinical record review for Patient #6 was completed on 02/27/13. The clinical record review revealed the 21-year-old patient presented to the emergency department on 02/17/13 at 12:40 P.M. with a chief complaint of hearing voices after he/she had been baptized. An emergency physician record dated 02/17/13 at 12:50 P.M. stated Patient #6 denied being suicidal but was maybe going to hurt some children. The behavioral health assessment dated 02/17/13 at 12:57 P.M. stated after babtism the patient heard the devil tell him/her he/she made the wrong decision. The patient was discharged on 02/18/13 at 12:19 A.M. The clinical record did not reveal during the patient's nearly 12 hour stay nursing reassessed him/her for hallucinations or other psychological symptoms. The emergency physician record was signed by a nurse practitioner on 02/17/13 at 8:16 P.M. and the physician, whose signature was not timed. The physician did not mark whether he/she agreed with the assessment and care plan of nurse practitioner.

The Medical Staff Bylaws were reviewed on 02/27/13. The bylaws stated in the emergency setting, all patients following triage, will undergo an appropriate medical screening exam and be offered stabilizing treatment either by the ED physician or an attending physician that is a qualified member of the medical staff.


The clinical record review for Patient #7 was completed on 02/27/13. The clinical record review revealed a triage note dated 02/25/13 at 7:05 P.M. that stated the patient's chief complaint was that the patient was fighting with her/his mother and the patient wanted to kill self by slicing throat. The clinical record review revealed a crisis assessment dated 02/25/13 at 8:15 P.M. that stated the patient was having auditory and visual hallucinations of ghosts telling the patient they are going to kill the patient and that the patient became possessed by demons that make the patient say things the patient doesn't want to say. The patient was discharged to a psychiatric facility on 02/26/13 at 2:40 A.M. The clinical record review did not reveal any nursing assessment after triage to determine whether the patient continued to hear voices or see ghosts during the patients nearly seven hour stay in the emergency department. The Assessment and Reassessment of Patients policy states the registered nurse will perform an assessment throughout the patient stay.

The clinical record review for Patient #1 was completed on 02/27/13. The 28-year-old patient presented to the emergency department on 02/25/13 at 2:34 P.M. with a chief complaint of suicide ideation. The triage nursing note dated 02/25/13 at 2:45 P.M. stated the patient had a suicide plan , was depressed, and an application for emergency (involuntary) admission was completed. The application for emergency (involuntary) admission dated 02/25/13 revealed Patient #1 reported hearing the voice of deceased uncle telling the patient to kill self. The patient stated that deceased uncle molested her when 10 years old and she believes the deceased uncle will hurt her.

The emergency physician record dated 02/25/13 at 2:47 P.M. stated the patient had been having auditory hallucinations "for a while", but was worse that weekend. The physician's order sheet dated 02/25/13 at 4:50 P.M. stated the patient was medically clear for a psychiatric evaluation. A nursing note dated 02/25/13 at 8:29 P.M. stated the patient tried to run when doors near her room opened. The clinical record review does not reveal a clinician's assessment for hallucinations, generalized anxiety, or other reasons to determine the reason for the attempt to elope. The record revealed a physician's order dated 02/25/13 at 8:20 P.M. for medication that read 20 milligrams of Geodon (a medication used for the treatment of depression).

The disposition was listed as a transfer to a psych unit, stable, at 5:10 P.M. on 02/25/13. The disposition was signed by a physician assistant. Physician A marks the box "I agree with the assessment and care plan, and confirm the diagnosis(es) above" and signs. The physician order sheet signed by Physician A has "transferred to" circled (does not say where). The physician order sheet also had "d/c" written on it. The emergency physician record listed the patient's clinical impression as bipolar disorder and schizophrenia.

The clinical record review did not reveal where the application for emergency (involuntary) admission was rescinded. On 02/26/13 at 4:00 P.M. in an interview, Physician B stated he/she let the patient go home and wrote "d/c" in the chart. Physician B stated he/she never signed his/her name to the chart. Although Physician B said he/she never examined the patient, he/she was okay with letting the patient go home. Physician B said the patient was allowed to go home based on the social worker's assessment. Although Physician B said he/she relieved Physician A , there isn't any indication in the patient's clinical record to support this.

The clinical record review revealed a face to face crisis assessment note dated (no time) 02/25/13 by a social worker. The note stated the patient had auditory hallucinations commanding the patient to harm herself. The note stated he/she has had some decrease in symptoms since arriving at emergency department because he/she feels he/she is safer there. Review of the