HospitalInspections.org

Based on policy review, Quality Performance Improvement Plan review, medical record review, Emergency Medical Services (EMS) trip report review, incident report review, observations, environmental risk assessment review, pharmacy unit inspection review, personnel file review, hospital document review and staff and provider interviews, the hospital's governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights to ensure a safe environment for emergency department patients; failed to maintain an organized and effective quality assessment and improvement program; failed to have an organized nursing service to meet patient care and safety needs and failed to meet the emergency needs of patients.

The findings included:

1. The hospital's leadership failed to ensure a medical provider was responsible for monitoring and ensuring the delivery of care to patients presenting to the emergency department. Nursing staff failed to provide care to emergency department (ED) patients by failing to triage upon arrival, assess, monitor, and provide care and treatment as ordered for 11 of 35 ED records reviewed (#92, #83, #43, #28, #27, #29, #6, #1, #2, #12 and #26).

Cross refer to §482.12 Governing Body Standard: Tag A 0068.

2. The hospital's leadership failed to ensure emergency care and services were provided according to policy and provider orders by failing to accept patients upon arrival to the emergency department, evaluate, monitor and provide treatment to emergency department patients to prevent delays and/or lack of triage, nursing assessment, and implementation of orders, including lab, telemetry and medication orders for 11 of 35 ED records reviewed (#92, #83, #43, #28, #27, #29, #6, #1, #2, #12 and #26).

Cross refer to §482.12 Governing Body Standard: Tag A 0092.

3. The hospital staff failed to ensure a safe environment for behavioral health patients subject to self-harm in the ED by failing to limit environmental risks in the Emergency Room pods (cluster of rooms in a designated area) used to house Behavioral Health patients awaiting placement (Green Pod and Purple Pod).

Cross refer to §482.13 Patient Rights' Standard: Tag A 0144.

4. The hospital staff failed to ensure tracking and trending of medical errors by failing to document incidents for improvement opportunities and failing to investigate potential causes and identify corrective action for 7 of 94 sampled patients reviewed (#58, #27, #59, #50, #13, #50, #2).

Cross refer to §482.21 Standard: QAPI Quality Improvement Activities, Tag A 0286.

5. The hospital's leadership failed to provide oversight and responsibility of the quality improvement program to ensure medical errors were tracked and trended, failed to document incidents for improvement opportunities and failed to investigate potential causes and identify corrective action for 7 of 94 sampled patients reviewed. (#58, #27, #59, #50, #15, #13 and #2).

Cross refer to §482.21 Standard: QAPI Standard: Tag A 0309.

6. The hospital's emergency department staff failed to ensure adequate nursing staff was available to provide and monitor the delivery of assessments, care, and treatment in the emergency department for 4 of 35 sampled ED records reviewed (Patients #28, #43, #27, and #2).

Cross refer to 482.23 Nursing Standard: Tag A 0392.

7. The hospital's nursing leadership staff failed to ensure policies were implemented to evaluate, monitor and provide treatment for patients presenting to the emergency department resulting in delays and lack of triage, nursing assessment, monitoring, and implementation of lab, telemetry, medication and treatment orders for 11 of 35 ED records reviewed (#92, #83, #43, #28, #27, #29, #6, #1, #2, #12 and #26).

Cross refer to §482.23 Nursing Standard: Tag A 0398.

8. The hospital nursing staff failed to administer medications and biologicals according to provider orders and standards of practice by failing to administer medications as ordered and evaluate and monitor the effects of the medication for 6 of 35 patients presenting to the emergency department (#92, #83, #43, #28, #27, and #26).

Cross refer to §482.23 Nursing Standard: Tag A 0405.

9. The hospital staff failed to have available laboratory services to meet the identified turn around times for STAT results for 3 of 35 patients presenting to the hospital's emergency department (#83, #27, #2), and failed to ensure timely laboratory results for 3 of 3 patients that had lab specimens sent to Hospital A's lab from Hospital B (#11, #93 and #94).

Cross refer to §482.27 Laboratory Services Standard: Tag A 0583.

10. Emergency department (ED) nursing staff failed to ensure emergency care and services were provided according to policy and provider orders by failing to accept patient upon arrival to the ED, evaluate, monitor and provide treatment to emergency department patients to prevent delays and/or lack of triage, nursing assessment, and implementation of orders, including lab, telemetry and medication orders for 11 of 35 ED records reviewed (#92, #83, #43, #28, #27, #29, #6, #1, #2, #12 and #26).

Cross refer to §482.55: Emergency Services Standard Tag A 1101.

Based on policy review, medical record review, Emergency Medical Services (EMS) trip report review, incident report review, and staff and provider interviews, the hospital's leadership failed to ensure a medical provider was responsible for monitoring and ensuring the delivery of care to patients presenting to the emergency department. Nursing staff failed to provide care to emergency department (ED) patients by failing to triage upon arrival, assess, monitor, and provide care and treatment as ordered for 11 of 35 ED records reviewed (#92, #83, #43, #28, #27, #29, #6, #1, #2, #12 and #26).

The findings included:

Review of the Quality Improvement Plan approved by the hospital Chief Executive Officer (CEO), Board of Trustees Chair and Chief Medical Officer (CMO) on 04/24/2023 revealed, " ...The hospital-wide Performance Improvement Plan is designed to improve quality performance and patient safety, ultimately reducing the risk to patients. ... ACCOUNTABILITY ... The following individual and/or committees are accountable for setting expectations, developing plans, and implementing procedures to assess, improve quality, and measure performance improvement within the organization. ... Medical Executive Committee ... Medical Staff / Medical Staff Department Chairman. The Medical staff shall be responsible to participate in the Performance Improvement Plan to the degree necessary and appropriate to achieve the purpose of the plan. Medical Staff members will be appointed to various Medical Staff Committees. These committees shall be responsible for implementing and maintaining an effective system to monitor and evaluate the quality and appropriateness of care ... The medical staff department chairs will participate in the Campus Executive Committee or Medical Executive Committee, as applicable. Participation will include monitoring metrics, developing criteria, evaluating results, ensuring resolution, and reporting findings to the appropriate medical staff department. ..."

Review on 12/06/2023 of the hospital policy "Triage - Emergency Department 1PC.ED.0401" revised 07/2023 revealed, "...DEFINITIONS: ... A. Triage Assessment: The dynamic process of sorting, prioritizing, and assessing the patient and is performed by a qualified RN (Registered Nurse) at the time of presentation and before registration. This is a focused assessment based on the patient's chief complaint and consists of information, which is obtained that would enable the Triage RN to determine minimal acuity. A rapid or comprehensive triage assessment is completed, with a goal of 10 minutes, on arrival to the emergency department. 1. A rapid triage assessment is composed of airway, breathing, circulation and disability, general appearance, eliciting symptom driven presenting complaint(s), and any pertinent objective and subjective data/assessment from the patient or parent or caregiver. 2. A comprehensive assessment, performed on each patient that presents to the emergency department, is a focused physical assessment including vital signs, pain scale, allergy, history of current complaint, current medications, exposure to infectious disease, and pertinent past medical/surgical history. ... B. Triage Acuity Level - The Emergency Severity Index (ESI) is a five level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs. C. Reassessment - A process of periodic re-evaluation of the patient's condition and symptoms prior to and during the initiation of treatment. Reassessment components may include some or all of the following: vital signs, a focused physical assessment, pain assessment, general appearance, and/or responses to interventions and treatments. Reassessment after the medical screening exam are performed by RN's (Registered Nurses) according to acuity or change in patient's condition. D. Vital Signs - Helps nursing personnel determine the stability of patients and acuity of those that are that are presenting with life-threatening situations or who are in high-risk categories. Usually refers to temperature, pulse rate, respiratory rate, and blood pressure. May include pulse oximetry for patients presenting with respiratory and/or hemodynamic compromise, and pain scale for those patients with pain as a component to their presenting complaint...PROCEDURE: ...B. All patients presenting for care will be evaluated by an RN. This RN should complete a brief evaluation of the patient, including immediate compromise to a patient's airway, breathing, or circulation.... H. If there is no bed available, the patient will need to wait in the lobby. While in the lobby, patient reassessment and vital signs should be documented in the health record in accordance with documentation guidelines. ..."

Review on 12/09/2023 of the "Assessment and Reassessment" policy revised 06/2021 revealed, "... PURPOSE: A. The goal of the assessment/reassessment is to provide the patient the best care and treatment possible ... The nursing process is utilized in order to achieve this goal. This process includes assessing, analyzing, planning, implementing, and evaluating patient care or treatment. ... DEFINITIONS: A. Assessment: The multidisciplinary assessment process for each patient begins at the point where the patient enters a (facility name) facility for care, and in response to changes in the patient's condition. ... The assessment will include systematic collection and review of patient-specific data necessary to determine patient care and treatment needs. B. Reassessment: The reassessment process is ongoing and is also performed when there is a significant change in the patient's condition or diagnosis and in response to care. ... SECTION VI: EMERGENCY DEPARTMENT: A. Patients should be triaged following guidelines set forth in the system Triage Policy (1PC.ED.0401), including documentation of required elements within the electronic medical record (e.g. Vital signs, Glasgow Coma Scale (GCS)). B. The priority of data is determined by the patient's immediate condition. On arrival to unit, an initial assessment is initiated, and immediate life-threatening needs are determined with appropriate interventions implemented. C. Patient assessment should be performed based on the developmental, psychosocial, physiological, and age-specific needs of the individual. D. Focused patient history and physical assessment are based on patient's presenting problem(s) including individual indicators of vulnerability. E. Reassessment: 1. Reassessment is ongoing and may be triggered by key decision points and at intervals based on the needs of the patients. Additional assessment/reassessment elements and frequency are based upon patient condition or change in condition, diagnosis, and/or patient history, not to exceed four hours. Interventions may warrant more frequent assessments...."

1. Closed medical record review on 12/09/2023 of Patient #92 revealed a 69 year-old male that presented to the emergency department on 11/09/2023 at 1149 via private vehicle with a chief complaint of chest pain. The patient was triaged at 1155 with a chief complaint of "Woken from sleep at 0400 with midsternal chest pain, described as sharp and pressure. No SOB (shortness of breath), arm/jaw/back pain, or diaphoresis (sweating). H/o (history of) colon CA (cancer) with mets (metastasis) to the lung, currently on chemotherapy...." Review revealed vital signs of blood pressure (BP) 125/60, pulse (P) 57, temperature (T) 97.4 degrees Fahrenheit, oxygen saturation (O2 Sat) 97% and a pain level reported as 2 (scale 1-10 with 10 the worst). Review revealed a triage level of 2 (level 1 most urgent). Review revealed a Medical Screening Examination by a physician was started in the waiting room area at 1209. Review of the physician's notes recorded the patient's chest pain had been waxing and waning, coming in waves and lasting about five minutes at a time. Review revealed a plan to conduct an ED chest pain work-up including a chest x-ray, EKG and labs including CBC, chemistry, lipase and troponin, and administer a dose of aspirin. Review recorded a differential diagnosis of GERD (gastroesophageal reflux disease), referred abdominal pain, musculoskeletal chest pain, ACS (acute coronary syndrome), with lower suspicion for PE (pulmonary embolus) given no tachycardia, hypotension, or evidence of DVT (deep vein thrombosis) on exam. Review revealed the ED physician recommended admission for further chest pain workup based on risk factors. Review of physician's orders revealed labs were ordered at 1218, collected at 1320 and resulted at 1332. Review revealed a troponin result of 0.013 (normal). Review revealed a physician's order placed at 1218 for continuous ECG (telemetry) monitoring in the ED. Review of the ED record revealed no evidence that continuous ECG monitoring was initiated in the ED. A chest x-ray was ordered at 1220 and resulted at 1246 with normal results. An EKG was completed at 1224 which showed sinus rhythm with premature atrial complexes (PACs), with no changes when compared with a prior EKG done in 2022 per the physician's read. A troponin resulted at 1320 as 0.013 (normal) and a baby aspirin was administered as ordered at 1334. A second troponin ordered at 1607 and resulted at 1704 as 0.014 (normal). Review of a second EKG completed at 1628 revealed "Sinus rhythm with premature atrial complexes (PACs). Otherwise normal ECG. When compared with ECG of 09-Nov-2023 12:24, Non-specific change in ST segment in inferior leads. ST elevation now present in Lateral leads." Review recorded the ECG was confirmed by a physician on 11/09/2023 at 1821. Review revealed a physician's order at 1659 for nitroglycerine 0.4 milligrams (mg) sublingual every five minutes times three as needed (prn) chest pain. Record review revealed no nursing assessment/reassessment documented after the patient's triage was recorded at 1155. The patient was administered Morphine (narcotic pain medication) 2 milligrams intravenously (IV) at 1703 by a medic for a pain level of 4. There was no reassessment of the patient's pain and no documentation of the patient's condition by a nurse. The patient was moved from the waiting room to a bed in the orange pod (admission holding area of the ED) at 1937. Nitroglycerine 0.4 milligrams sublingual was administered by a nurse times one for a pain level of 10 at 2013. Review revealed no reassessment of the patient's response to the medication intervention and no nursing assessment of the patient's condition was documented. The patient was transported from the ED to a medical surgical floor on 11/09/2023 at 2054. The patient was placed on continuous telemetry at 2111 when he was noted to be in Atrial Fibrillation with Rapid Ventricular Rate (abnormal heart rhythm). Review of the ECG completed at 2110 recorded an "ST elevation consider lateral injury or acute infarct ** ** ACUTE MI / STEMI (myocardial infarction or heart attack) ** ** ...". Review of a Cardiovascular Consult History and Physical documented on 11/10/2023 at 0020 as an Addendum revealed the patient "... went into AF/RVR (Atrial Fibrillation with Rapid Ventricular Rate) at 2110 hrs this evening with ECG demonstrating evolving high lateral STEMI (l, aVL) which was more pronounced on follow-up ECG at 2210 hrs prompting formal STEMI activation for emergent cardiac catheterization. ..." Review of a Discharge Summary dated 11/13/2023 at 1211 revealed the patient was discharged home on 11/13/2023 with a diagnosis of STEMI (ST elevation myocardial infarction), Coronary Artery Disease, Hypertension, and Atrial Fibrillation with RVR.

Interview on 12/09/2023 at 1210 with ADON #17 revealed Patient #92 was identified as a level 2 triage and should have been assessed every four hours at a minimum, every two hours for a level two and with any change in the patient's condition. Interview revealed the patient developed chest pain and required interventions and no nursing assessments or reassessments were documented in the ED record. Interview revealed continuous telemetry was ordered for the patient at 1218 and telemetry was not placed on the patient in the ED. Interview revealed the telemetry was placed on the patient at 2111 once the patient transferred to the medical floor.

Patient #92 presented to the ED with chest pain on 11/09/2023 at 1149. The patient was not assessed by a nurse after triage was completed at 1155, or with a change in condition, or after pain medication was administered at 1703. The patient was never placed on continuous telemetry in the ED as ordered by a physician at 1218. The patient was transferred to a medical floor and placed on telemetry at 2111 when he was found to be in atrial fibrillation with rapid ventricular rate, prompting a STEMI Code Activation. The patient underwent an emergency cardiac catheterization at 2249. ED nursing staff failed to ensure a safe environment for the delivery of care to Patient #92 by failing to provide ongoing assessment of the patient's condition and follow physician's orders for application of continuous telemetry.



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2. Review on 11/17/2023 of the hospital policy Turn Around Time, last revised 11/17/2021 revealed "...PURPOSE: To provide timely and efficient testing services for routine, critical and high-risk situations. DEFINITIONS: Turn Around Time (TAT): the time elapsed from order placement to result reporting. Categorized as: Pre-analytical Phase: the period between test order entry by the caregiver and specimen receipt in the Laboratory. May be influenced, but not controlled by the Laboratory. Analytical Phase: the period between specimen receipt in the Laboratory and result reporting. Controlled by the Laboratory...STAT: an emergent, potentially life-threatening request. NOW: as soon as possible. Synonymous with ASAP. POLICY: All tests will be performed without delay to maximize specimen quality and integrity. STAT, NOW ... requests will be managed as priority situations. First-in, First-out (FIFO) processes are utilized to facilitate rapid and efficient movement of specimens through the system. Requests are also prioritized based on the following criteria to meet defined turn-around times: ...Response to STAT requests: ...STATS take priority over other specimens and should be managed from time of receipt until result reporting with no interruption in handling or testing. In general, the maximum TAT for most tests is 45-50 minutes from order receipt.... Response to NOW/ASAP requests: ...Staff will immediately process the specimen, perform testing, and verify results. Results should be available within (1) one hour from specimen receipt.... TAT Summary (Inpatient): STAT, Time from ORDER Receipt 45-50 minutes. NOW, Time from SPECIMEN receipt 1 hour..."

Closed medical record review on 12/06/2023 revealed Patient #83, a 74-year-old female patient who arrived at the emergency department (ED) via emergency medical services (EMS) on 11/28/2023 at 1216 with a chief complaint of dizziness from her doctor's office. Patient #83 was seen by an ED MD #1 on arrival and at 1218 a comprehensive metabolic panel (CMP) [includes serum glucose] was included in laboratory tests ordered as STAT (an emergent, potentially life-threatening request) with continuous ECG monitoring. At 1259 Patient #83 was placed in Red Pod (for the most acute patients) Hallway Bed-17. At 1309 the first set of vital signs was recorded by RN #2 as temperature 98.7, heart rate 84, respirations 19, blood pressure 225/88, and oxygen saturation of 93 percent on room air. At 1316 RN #3 completed a nursing triage assessment and Patient #83 was given an emergency severity index (ESI) [level 1 as the most urgent and 5 as the least urgent] of 3-urgent. Review of the CMP history revealed the STAT lab was collected at 1358 by RN #3 (1 hour and 40 minutes after the order was placed), the blood specimen arrived at the laboratory at 1412, and resulted at 1532 (3 hours and 14 minutes after the STAT order was placed) with a serum glucose resulted of 1137 (high normal range 120). Review of the Physician's Order on 11/28/2023 at 1626 by ED Nurse Practitioner (NP) #5 revealed a new order for an Insulin (IV medication to reduce serum glucose) IV infusion to be started (54 minutes after the glucose had resulted). At 1709 an Insulin drip was initiated for Patient #83 by the RN #3. At 1739, the Hospitalist NP #6 placed a continuous telemetry monitoring order for 48 hours for Patient #83, with vital signs every 2 hours while in the ED. At 1908 ED MD #14 ordered a Glycosylated Hemoglobin NOW that was collected at 2128 (2 hours after ordered). At 2109 Patient #83 was moved to the ED Holding-Orange Pod-Room-2 awaiting an inpatient bed. At 2329 Hospitalist MD #9 ordered an IV infusion of D51/2 NS with KCL (Dextrose, Normal Saline, and Potassium Chloride Solution). On 11/29/2023 at 0127 MD #9 ordered a Lactic Acid (carries oxygen from your blood to other parts of your body) level to be drawn "NOW" for "nurse collect" for Patient #83. At 0153 MD #9 ordered to suspend the insulin IV. An addendum was made to the History and Physical at approximately 0200 by MD #9 which revealed "...Unfortunately patient has been on insulin drip since 5pm without continuous fluid administration or repeat blood work, it is currently 2 am, Nursing staff was previously contacted requesting these, later on did let provider know there was difficulty obtaining blood work as well as delay in obtaining D51/2NS KCL fluid from pharmacy. Given we have no blood work, no fluids, for the safety of the patient will suspend insulin drip at this time, until blood work is back to ensure appropriateness of insulin drip infusion..." 0157 RN #10 documented the IV with D51/2NS KCL as started (2 hours and 27 minutes after ordered). At 0200 Patient #83's Insulin IV was suspended by RN #10. At 0256 Patient #83's Insulin IV was reordered and was resumed (56 minutes after it was stopped). On 11/29/2023 at 0514 Patient #83 was transported to a Stepdown Unit. Review of the ED record revealed no evidence that continuous telemetry monitoring or vital signs every 2 hours were initiated in the ED by a nurse, further the NOW Lactic Acid "nurse collect" order at 0127 was never drawn while the patient was in the ED. On the inpatient floor, at 0529, RN #11 cancelled the 0127 NOW Lactic Acid order "nurse collect" from the ED and reordered the NOW Lactic Acid order "lab collect". The Glycosylated Hemoglobin NOW that was ordered 11/28/2023 at 1908 resulted on 11/29/2023 at 0743 (12 hours and 35 minutes after ordered) with result of 12.3 (normal high range 6.3). At 0844 the Lactic Acid was drawn (3 hours and 15 minutes after it was ordered), was in the lab for processing at 0907, and resulted at 1108 (5 hours and 39 minutes after ordered) as "7.48" (high normal for lactic acid was 2.1). The computer system automatically reordered an additional Lactic Acid order by default and was collected at 1119 and was in the lab to be processed at 1148. At 1146 RN #12 documented a blood pressure of 141/67 with respirations of 36. At 1158 Rapid Response was called for Patient #83. At 1206 blood pressure was 65/40. At 1213 blood pressure was recorded at 68/40. At 1225 a Levophed (medication used to increase blood pressure) IV infusion was initiated via interosseous to increase her blood pressure. At 1245 the blood pressure was 126/84 at 98 percent oxygen saturation while the patient was being mechanically bagged at the bedside. At 1247 Patient #83 was intubated (mechanical ventilation), at 1250 Patient #83 was transferred to the medical intensive care unit. At 1256 the second Lactic Acid resulted as critically high "11.96". After discussion with the family, Hospitalist MD #16 changed Patient #83 Full Resuscitation status to Limited Resuscitation with no cardiopulmonary resuscitation (CPR). Patient #83 expired on 11/30/2023 at 1337.

Review on 12/06/2023 of a Patient Safety Analysis (Incident Report) completed by RN #12 on 12/01/2023 at 1917 revealed this Care Event was a "Delay in Care" and the issue was "Lack of timely response to Order", for Patient #83. A description "A NOW LA (lactic acid) order was placed at 0529. Lab wasn't drawn until 0844, and in lab at 0907. Critical results of lactic acid 7.48 reported at 1108. MD at 1114...Shortly after this (within the hour), the patient took a turn and had to be intubated at bedside and sent to ICU (intensive care unit) ...Solution to Prevent this from Recurring? Promptly follow orders..." This Patient Safety Report was still in process. Review of the report revealed Patient #83 had a delay in lab work.

Request to interview MD #9 revealed she was unavailable for interview.

Request to interview MD #16 revealed he was unavailable for interview.

Telephone interview on 12/07/2023 at 1632 with RN #10 who cared for Patient #83 in the Orange Pod (location in the ED for pending admissions) revealed "...I work on an inpatient unit and was pulled to the ED that day. It's a revolving door, I don't recall this patient in particular. If I can't get the labs, I would call a phlebotomist after 3 tries to get the labs if I couldn't..." Interview revealed she could not remember why the NOW lactic acid order was not collected. Interview revealed physician orders for Patient #83 were not followed.

Interview on 12/08/2023 at 0915 with RN #11 revealed she did remember Patient #83 and worked night shift. "...I did not receive a report on this patient from the ED. You have to look up the medical record number and sometimes the charge nurse gets an alert that the patient is coming and will print the face sheet. I had to piece it together and go through the orders. I reordered the lab work when I saw it was pending. My concern is we have had trouble getting in contact with the phlebotomist. That morning they were not logged into to their imobile device. I called the general lab number, and no one answered. I then contacted my house supervisor, and he told me 'we don't have another option right now.' I can't recall if she was on a telemetry box or not, I was only with her over an hour..." Interview revealed not being able to reach a phlebotomist during night shift had happened before. Interview revealed RN #11 had called multiple times to reach the lab phlebotomist to draw NOW blood orders without reaching someone. Interview revealed lab Turn Around Time for NOW lab orders was not followed for Patient #83.

Interview on 12/08/2023 at 1309 with Laboratory Phlebotomist Supervisor #17 revealed "...the phlebotomists do not collect in the ED; we will help if called. All labs ordered in the ED default to "nurse collect". The expectation was for STAT and NOW orders to be from order to collection in 15 minutes and to be resulted in an hour from order..." Interview revealed lab collection for STAT and NOW orders for Patient #83 did not follow hospital policy for lab turnaround times.

Interview on 12/08/2023 at 1414 with NP #6 revealed her expectation for Patient #83, was for her to have continuous ECG monitoring and vital signs every 2 hours while in the ED. Interview revealed physician orders were not followed for Patient #83.

Interview on12/08/2023 at 1425 with RN #3 who cared for Patient #83 in the Hallway Bed 17 on 11/28/2023 revealed "...I remember her. It was an extremely busy day...she was a hard stick; I used an ultrasound to start her IV. The problem with hallway beds is they have no dedicated monitor. She had a monitor and vital signs ordered. I strongly advocated for her to get moved into a bed with the CNC (clinical nurse coordinator), and it didn't happen. She didn't think it was a big deal. We don't have the capability to link the patient to a monitor in a hallway bed. She wasn't on a monitor; I spent the afternoon telling the CNC and MD. The doctors don't have any say, it's up to the CNC where patients are roomed. I sat behind her all day, ...I was extremely frustrated..." Interview revealed Patient #83 was not placed on continuous ECG monitoring, nor were vital signs monitored every 2 hours. Interview revealed physician orders were not followed for Patient #83.

Interview on 12/08/2023 at 1230 with Nursing VP of ED Services, VPED #20 revealed she could not explain the lack of telemetry monitoring or vital signs for Patient #83 while in the ED. Interview revealed the ED nurse should elevate to the ED Charge Nurse for the need to continuously monitor a patient in a hallway bed if one was not available. Further interview revealed the ED Provider and ED Nurse were responsible for monitoring lab results via electronic medical record in the ED. Interview revealed hospital policy was not followed for Patient #83.

Interview on 12/09/2023 at 1159 with Lab Director #18 revealed "...I do know we had a call out that day. The lactic acid was available for the lab tech to see at 1016 but wasn't called to the floor until 1108. I don't know what the delay was. The expectation was to call as soon as the result was available. The expectation for lab collection and processing was to follow the policy guidelines, and for STAT and NOW results to be completed within an hour..." Interview revealed lab collection and processing did not follow hospital policy for Patient #83.

Patient #83 was presented to the ED with dizziness on 11/28/2023 at 1216. The patient had STAT lab work ordered at 1218 with continuous ECG monitoring. Labs were drawn at 1358 (1 hour and 40 minutes after ordered). Labs arrived at the lab at 1412 and resulted at 1532 (3 hours and 14 minutes after ordered). The blood glucose was 1137 (critically high). Insulin IV infusion was ordered at 1626 and initiated at 1709 (1 hour and 13 minutes after ordered and 1 hour and 37 minutes after the glucose resulted). Orders for continuous ECG monitoring placed at 1218, and vital signs every 2 hours were never initiated in the ED. At 2349 an IV infusion of D51/2 KCL was ordered that was not completed until 0157 (2 hours. and 8 minutes after ordered). Lactic acid was ordered NOW at 0127 for nurse collect in the ED. At 0200 a physician wrote there was a delay in labs and fluids so stopped the insulin IV infusion. The lactic acid was not collected in the ED. At 0529 the original lactic acid NOW, order was cancelled and reordered as lab collect NOW on the floor. It was collected at 0844 (3 hours and 15 minutes after ordered at 0529) and resulted at 1108 (9 hours and 41 minutes after originally ordered at 0127) with a result of 7.48 critical high. A second lactic acid was reordered at 1108 and resulted at 1256 (1 hr. and 36 minutes after ordered) with a result of 11.96 critically high. A rapid response was called previously at 1158, the patient was intubated at 1247, and ultimately expired on 11/30/2023.

3. Review of the CIWA (Clinical Institute Withdrawal Assessment for Alcohol) /Alcohol Withdrawal Plan, effective date 07/20/2022 revealed "...Monitoring Phase ...Now ONCE, when plan is initiated with goal CIWA < (less than) 15..." The CIWA/Alcohol Withdrawal Plan Reference Information included 10 questions, questions 1-9 can score between 0 and 7 points each question, question 10, can score 0 to 4 points, depending on severity of symptoms for each question. Score range 0-68. Questions with observations: 1. Nausea/Vomiting? 2. Paroxysmal sweats? 3. Agitation? Headache, fullness in head? 5. Anxiety? 6. Tremor? 7. Visual disturbances? 8. Tactile disturbances? 9. Auditory disturbances? 10.Orientation and clouding of sensorium -Ask what day it is? "...CIWA Management Communication If CIWA > 15 for four consecutive hours, contact provider to initiate Severe Withdrawal Phase and/or to consider transfer to higher level of care..."

Closed medical record review on 11/16/2023 revealed Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of "...chest pain, nausea, clammy, lightheaded, and right-side tingling for several week. Drinks 12 beers a day...." At 1603 triage by Registered Nurse (RN) #21 with vital signs: temperature 98.5, heart rate 97, respirations 18, blood pressure141/89, oxygen saturation of 96 percent on room air, and pain of 4/10 (1 being least pain, and 10 being most pain) and was assigned an emergency severity index [ESI] (level 1 as the most urgent and 5 as the least urgent) of 2. Patient #43 was then moved to the ED waiting room IPA (Internal Processing Area) area and was seen by Nurse Practitioner (NP) #22. At 1650 initial labs, ekg, and chest Xray were completed, and Patient #43 was assigned to ED Medical Doctor (MD) #23. Review of the ER Physician Note from 08/14/2023 at 1727 by MD #23 revealed a review of lab, ekg and chest Xray results from 08/14/2023 did not show any critical results. At 1732 MD #23 ordered a GI cocktail (oral combination of medications given for indigestion), Zofran 4mg orally (medication given for nausea and vomiting). An addendum to MD #23's ER Report Note revealed "...On reassessment patient and his mom who is now accompanying him are updated on his results. He is still in the waiting room unfortunately. I have ordered IV (intravenous) fluids, CIWA protocol and 1mg of Ativan (a sedative given for anxiety and seizures) as he is slightly tremulous (shaking) and diaphoretic (sweating) my reassessment [sic]...Hospitalist has been consulted for admission..." At 1841 MD #23 placed orders for IV (intravenous) fluids-NS NOW, thiamine (dietary supplement/nutrient) 100 milligrams (mg) orally STAT (immediately), and CIWA scale/protocol (alcohol withdrawal plan/protocol). At 1851 vital signs were rechecked by IPA ED RN #24 temperature 98.3, heart rate of 103, blood pressure 132/82, and oxygen saturation of 92 percent on room air, the GI Cocktail, and Zofran were administered in the ED waiting room. At 1947 MD #23 ordered Ativan 1mg IV push NOW (urgent). Per the CIWA plan at 2100 a multivitamin orally was ordered and CIWA Scale assessment. The History and Physical was initiated on 08/14/2023 at 2229 by Hospitalist MD #25 while in the ED waiting room, and new orders were placed for aspirin orally NOW, Lopressor (medication given in treatment of alcohol withdrawal) 12.5 mg orally, and again IV access at 2226. At 2305 MD #25 ordered Patient #43 phenobarbital (medication given to prevent seizure) 60 mg orally three times a day STAT and a CIWA Scale reassessment was due to be completed per protocol. No nursing reassessments, medication administrations, IV access/fluids, or physician orders were completed after 1851 for Patient #43 while in the ED waiting room. On 08/15/2023 at 0057 Patient #43 was moved to the Red Pod (ED area for the most acute patients) room 11. At 0105 MD #25 ordered Patient #43 to have Ativan 4mg IV STAT and was given at 0106 by RN #27. Review of the ER Report Note on 08/15/2023 at 0107 by MD #26 revealed "...I became involved in the patient's care after he apparently left the waiting room where he was awaiting admission and then had a seizure and struck his head on the sidewalk outside of the ER (emergency room) entrance. On my evaluation, the patient seems postictal (the period following a seizure, disorienting symptoms, confusion, and drowsiness), he is not actively seizing. He does have a history of heavy alcohol use, drinks about 12 beers a daily. He has been in the emergency department waiting room for 9 hours and has not received any Ativan or Phenobarbital. I suspect that he seized due to alcohol withdrawal. Will obtain head CT (cat scan) given the patient did strike his head, he also has a small laceration that will require repair...." Record review revealed the ED waiting room orders for IV fluids NOW on 08/14/2023 at 1841 to 08/15/2023 at 0106 (5 hrs. and 25 min), Ativan IV NOW ordered on 08/14/2023 at 1947 to administered on 08/15/2023 at 0106 (5 hours 19 min), and Phenobarbital STAT ordered on 08/14/2023 at 2305 to administered on 08/15/2023 at 0150 (2 hours and 45 min) for Patient #43 were delayed and no CIWA score/assessment was completed until 08/15/2023 at 0437 (9 hours and 56 minutes after ordered). No CIWA score/assessment was documented before the patient had a seizure event with sustained head injury. There was no nursing reassessment, or nursing care after 08/14/2023 at 1851 by RN #22 until 08/15/2023 at 0057 (6 hours and 1 minute). Patient #43 was admitted to an inpatient room on 08/15/2023 at 0334 from the ED. Patient #43 was discharged home on 08/17/2023.

Review of the Patient Care Analysis (Inciden

Based on policy review, medical record review, incident report review, Emergency Medical Services (EMS) trip report review, and staff and provider interviews, hospital leadership failed to ensure emergency care and services were provided according to policy and provider orders by failing to accept patient upon arrival to the emergency department, evaluate, monitor and provide treatment to emergency department patients to prevent delays and/or lack of triage, nursing assessment, and implementation of orders, including lab, telemetry and medication orders for eleven (11) of 35 ED records reviewed (#92, #83, #43, #28, #27, #29, #6, #1, #2, #12 and #26).

The findings included:

Cross refer to all findings at §482.55: Emergency Services A 1100.

Emergency Department (ED) nursing staff failed to ensure emergency care and services were provided according to policy and provider orders by failing to accept patient upon arrival to the ED, evaluate, monitor and provide treatment to emergency department patients to prevent delays and/or lack of triage, nursing assessment, and implementation of orders, including lab, telemetry and medication orders for eleven (11) of 35 patient records reviewed (Patient #'s 92, 83, 43, 28, 27, 29, 6, 1, 2, 12 and 26).

1. Patient #92 presented to the ED with chest pain on 11/09/2023 at 1149. The patient was not assessed by a nurse after triage was completed at 1155, or with a change in condition, or after pain medication was administered at 1703. The patient was never placed on continuous telemetry in the ED as ordered by a physician at 1218. The patient was transferred to a medical floor and placed on telemetry at 2111 when he was found to be in atrial fibrillation with rapid ventricular rate, prompting a STEMI Code Activation. The patient underwent an emergency cardiac catheterization at 2249. ED nursing staff failed to provide ongoing assessment of the patient's condition and follow physician's orders for application of continuous telemetry. Nursing staff failed to ensure policies and provider orders were implemented.

2. Patient #83 was presented to the ED with dizziness on 11/28/2023 at 1216. The patient had STAT (immediate) lab work ordered at 1218 with continuous ECG monitoring. Labs were drawn at 1358 (1 hour and 40 minutes after ordered). Labs arrived at the lab at 1412 and resulted at 1532 (3 hours and 14 minutes after ordered). The blood glucose was 1137 (critically high). Insulin IV infusion was ordered at 1626 and initiated at 1709 (1 hour and 13 minutes after ordered and 1 hour and 37 minutes after the glucose resulted). Orders for continuous ECG monitoring placed at 1218, and vital signs every 2 hours were never initiated in the ED. At 2349 an IV infusion of D51/2 KCL was ordered that was not completed until 0157 (2 hours. and 8 minutes after ordered). Lactic acid was ordered NOW at 0127 for nurse collect in the ED. At 0200 a physician wrote there was a delay in labs and fluids so stopped the insulin IV infusion. The lactic acid was not collected in the ED. At 0529 the original lactic acid NOW, order was cancelled and reordered as lab collect NOW on the floor. It was collected at 0844 (3 hours and 15 minutes after ordered at 0529) and resulted at 1108 (9 hours and 41 minutes after originally ordered at 0127) with a result of 7.48 critical high. A second lactic acid was reordered at 1108 and resulted at 1256 (1 hr. and 36 minutes after ordered) with a result of 11.96 critically high. A rapid response was called previously at 1158, the patient was intubated at 1247, and ultimately expired on 11/30/2023.

3. Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of chest pain, nausea, clammy, lightheaded, right-side tingling for several weeks, with a reported history of drinks 12 beers a day. Review revealed the patient was located in the waiting room area and was observed by a physician to be diaphoretic. The physician ordered intravenous (IV) fluids and CIWA protocol (assessment tool used for alcohol withdrawal) at 1841, and Ativan (medication for anxiety) was ordered at 1947. These orders were not implemented. Multivitamin was ordered at 2100. Another order was placed at 2226 for IV fluids and Lopressor. Aspirin was ordered at 2229. None of these orders were implemented. An order written at 2305 for Phenobarbital administration was not implemented. At 0107, a physician's note referenced the patient had a seizure and fall with a head injury outside the ED waiting room area. Findings revealed the patient had delays with nursing assessments, and failure to implement orders, including medication administration, and following the CIWA protocol. The patient subsequently had a seizure and fall with a resulting head injury.

4. Patient #28 presented to the ED on 07/05/2022, was critically ill, intubated and diagnosed with bacterial meningitis. The patient developed a low blood pressure and a Levophed IV drip was started. Findings revealed the Levophed IV drip was allowed to run dry and the patient's blood pressure dropped to 33/18. A trauma PA was requested by the family for help related to alarms and the patient's condition and the PA indicated the patient was not the PAs assigned patient. The patient arrested. A new Levophed bag was hung. The patient and IV were not monitored and the bag ran dry with subsequent cardiac arrest.

5. Patient #27 arrived in the ED on 07/04/2022 at 0025 with a reported pain level of 10 of 10. The patient had a STAT CT of the abdomen and pelvis ordered at 0027 that was not completed until 0755 (7 hours, 27 minutes later) resulted and signed at 0825. The patient had pain reported as 10 of 10, with nausea and vomiting with vital signs at arrival at 0025 and was medicated with Dilaudid (narcotic pain medication) at 0739 (7 hours and 14 minutes after arrival). The patient was diagnosed with a small bowel obstruction and had surgery that day. The patient had a delay with STAT lab work, STAT CT, nursing reassessment and pain management.

6. Patient #29 arrived on 04/05/2022 at 1451 via EMS and had atrial fibrillation (abnormal heart rhythm) on arrival. The patient had a recent fall with fracture prior to arrival. Pulse Oximetry was 94% prior to arrival. 1630 pulse oximetry was 90% (1 hour and 39 minutes after arrival) with no evidence of oxygen administration at hospital. Dilaudid 0.5 milligrams (mg) IV was administered at 1630 and at 1816. No vital sign or oxygen assessment on an elderly patient was assessed on the patient with a prior pulse oxygen of 90% after the administration of Dilaudid. The patient was subsequently asystole at 1909 and expired. Patient #29 had one set of vital signs from 1451 until time of death at 1909 (5 hours and 18 minutes). Nursing staff failed to reassess the patient after narcotic administration. Nursing staff failed to reassess the patient for a change in condition (not breathing).

7. Patient #6 arrived to Hospital B with strokelike symptoms at 10 days postpartum. She was accepted for transfer to Hospital A as an ED to ED transfer. Patient #6 arrived to the hospital via EMS on 10/03/2023 at 1942. The patient waited in the ED for a bed and continued to be managed by EMS. No documentation was noted by a medical provider until 2223 and Patient #6 was not triaged or assessed by hospital nursing staff until 2227 (approximately 2 hours 45 minutes after arrival by EMS). There was a delay in accepting the patient and a delay in triage, assessment and monitoring by nursing staff.

8. Patient #1 arrived as a transfer on 10/31/2023 at 2314 by EMS. No triage, nursing assessment or evaluation was completed in the ED. The patient was transported to the NSICU (Neurosciences Intensive Care Unit) on 11/01/2023 at 0105. A nursing note was written that stated the nurse was only transporting the patient to the inpatient unit and had not assumed care of the patient. The first nursing vitals or assessment were done at 0110 in NSICU. EMS monitored Patient #1 in the ED and nursing failed to accept, triage and provide care to a patient in the ED.

9. Patient #2 was brought to the ED by EMS from home. The patient arrived on 10/17/2023 at 1753 with chest pain and a syncopal episode at home. The provider ordered labs at 1841 (48 minutes after Patient #2 arrived), and the labs were not collected by nursing staff until 1920 (39 minutes after orders), after the patient was triaged at 1900 (1 hour and 7 minutes after arrival). The patient was on a cardiac monitor and received vital signs by EMS until triage at 1900. No hospital EKG was completed until 1905 (24 minutes after order and 1 hour 12 minutes after arrival). The elevated D-Dimer did not result until 2006, the elevated Pro BNP did not result until 2023 and the elevated Troponin did not result until 2039. At 1953 a physician responded to the patient's bedside due to a cardiac arrest. CPR was started and the patient expired. Nursing staff failed to accept the patient upon arrival to the ED, resulting in delayed triage, care and treatment.

10. Patient #26 presented to the ED via EMS on 09/01/2022 at 1845 for complaints of abdominal pain, decreased appetite, watery non-bloody diarrhea, and right-calf burn. Review of the patient's closed medical record lacked nursing documentation related to the assessment and treatment of the patient's right calf wound from presentation in the ED on 09/01/2022 through discharge on 09/07/2022.

11. Closed medical record review of Patient #12 revealed a 41 year old female transferred to the ED (emergency department) on 07/18/2023 at 1623 via EMS (emergency medical service) for abdominal pain, nausea, chills, and evaluation by general surgery for concerns of appendicitis. Record review revealed the patient did not have her vital signs monitored and had no nurse assigned to monitor status or provide care.





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Based on policy review, medical record review, Emergency Medical Services (EMS) trip report review, incident report review, observations, environmental risk assessment review and staff and provider interviews, the hospital staff failed to promote and protect patient's rights by failing to provide a safe environment to Emergency Department patients and failed to obtain authorization for psychotropic and nonpsychotropic medicinal interventions.

The findings included:

The hospital staff failed to ensure a safe environment for behavioral health patients subject to self-harm in the ED by failing to limit environmental risks in the Emergency Room pods (cluster of rooms in a designated area) used to house Behavioral Health patients awaiting placement (Green Pod and Purple Pod).

Cross refer to 482.13 Patient Rights' Standard: Tag A 0144.

The hospital nursing staff failed to obtain authorization for psychotropic and nonpsychotropic medicinal interventions for 1 of 4 sampled pediatric behavioral health patient records reviewed (Patient #75).

Cross refer to 482.13 Patient Rights' Standard: Tag A 0131.

Based on review of the "Authorization for Nonpsychotropic Medicinal Intervention" form, medical record review and interview, the nursing staff failed to obtain authorization for psychotropic and nonpsychotropic medicinal interventions for one (1) of four (4) sampled pediatric behavioral health patient record reviewed. (Patient #75).

The findings included:

Request for policy revealed the hospital staff advised there was no policy available. The hospital provided a consent form titled "Authorization for Nonpsychotropic Medicinal Intervention" which stated "By signing below I, as the Legally Responsible Person for the minor, _________, do hereby give my consent for the physician to perform medicinal intervention as related to the aforementioned minor. I understand that the physician will be using _______ as medication for the purpose of treating the minor for ________. I also understand that I can revoke this consent at any time" and "Authorization for Psychotropic Medicinal Intervention" which stated "By signing below I, as the Legally Responsible Person for the minor, _________, do hereby give my consent for the physician to perform psychotropic medicinal intervention as related to the aforementioned minor. I understand that the physician will be using _______ as medication for the purpose of treating the minor for ________. I also understand that I can revoke this consent at any time." The forms provided spaces for date/time, legally responsible person signature, relationship, and witness signatures.

Review on 12/04/2023 of the closed medical record for Patient #75 revealed a 12-year-old female that presented to the Emergency Department on 06/30/2023 at 2251 by law enforcement with Involuntary Commitment (IVC) paper for assault on therapist and mother. Patient #75 was admitted to inpatient behavioral health services on 07/01/2023 at 2027. Review of the Medication Administration Record (MAR) showed that Patient #75 was administered Zyprexa on 07/01/2023 at 0018, Melatonin and Trazodone at 0045, Prozac, Guanfacine, Lamictal and Quetiapine at 0817, Tylenol at 0913, Benadryl and Zyprexa at 1006 and Sarna Topical Lotion at 1035. Review of the medical record revealed a signed authorization/consent form dated 07/01/2023 at 1614 for the following psychotropic medicinal interventions: Zyprexa (15 hours and 56 minutes after administered), Trazodone (15 hours and 29 minutes after administered), Prozac, Guanfacine, Lamictal and Quetiapine (7 hours and 57 minutes after administered) Zyprexa (6 hours and 8 minutes after administration). Review of the MAR revealed that Patient #75 was administered Benadryl on 07/01/2023 at 1006 with no evidence of a signed authorization/consent form from the parent/guardian. Review of the medical record revealed a signed authorization/consent form dated 07/01/2023 at 1614 for the following non-psychotropic medicinal interventions: Melatonin (15 hours and 29 minutes after administered), Tylenol (7 hours and 1 minute after administered), and Sarna Topical Lotion (5 hours and 39 minutes after administered).

Interview on 12/06/2023 at 1520 with RN #84 revealed that consent forms should be obtained from the parent/legal guardian prior to administration of psychotropic and/or non-psychotropic medications to a minor.

Based on observations, review of the "Environmental Risk Assessment for Suicide Prevention" form, and staff and provider interviews, the hospital failed to ensure a safe environment for behavioral health patients subject to self-harm in the Emergency Department (ED) Pods (cluster of rooms in a designated area), and identify and/or remove potential environmental hazards that were located in the designated behavioral health area.

The findings included:


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Observation on 11/13/2023 at 1150 during tour of the emergency department (ED) revealed Green Pod had twelve patient care rooms, eight of which had adolescent behavioral health patients in them. Three of the eight patients had a sitter at the doorway of their room (Room 78, 80, and 83). Observation revealed all eight behavioral health patients had a corded call bell. Tour of the Purple Pod revealed a twelve-patient care room unit with eleven behavioral health adult patients in them. Observation revealed all eleven patients had corded call bells. There were two sitters for two of the eleven patients (Room 44 and 48). There were three rooms in the Purple Pod that had Hoyer lifts (device to assist with moving and lifting a patient who cannot move themselves) on the ceiling (Rooms 37, 42, and 45). The twelve rooms and the bathrooms in the Purple Pod had rectangle shaped hook(s) behind the door that were not breakaway hooks. Staffing consisted of two Registered Nurses and a Rover (a Patient Safety Attendant assigned to round every fifteen minutes on the patients in the unit).

Observation on 11/15/2023 at 1315 in the Purple Pod revealed eight behavioral health adult patients. The Rover (Patient Safety Attendant assigned to perform every fifteen-minute checks) took a corded telephone into Room 46 and left the room. The patient in the room did not have a virtual sitter nor a one-to-one sitter while having the corded telephone.

Observation on 11/30/2023 at 0947 during tour revealed there were four patients in the Green Pod with corded call bells. There were no sitters with the four patients. The patient in room 77 had a hospital bed with a fitted sheet on the bed instead of the behavioral health safe sheets (linen that is designed to not hold tied knots). Observation revealed Rooms 73 and 82 had bathrooms within the patient rooms. Each bathroom contained safety handrails that you could tie something completely around the rail, normal toilets, regular faucets on the sinks, and regular mirrors. Observation during tour of the Purple Pod revealed the Pod had been "flipped" back for non-behavioral health patients.

On 11/30/2023 a review of the "Environmental Risk Assessment for Suicide Prevention" performed on 09/08/2023 revealed any ligature risk identified were listed as being mitigated by monitoring needs that were put in place as identified by the suicide risk scores.

Interview on 11/27/2023 at 1500 with Acting Chief Nursing Officer (ACNO) #47 revealed that all the rooms are ED rooms and all the Pods in the ED were used for any type of ED patients. A behavioral health patient could be placed anywhere in the ED not only in the Blue Pod, or the current overflow Pods, Green and Purple, that were currently used to house overflow behavioral health patients. ACNO #47 stated that all behavioral health patients get a C-SSRS (Columbia Suicide Severity Rating Scale- assessment tool used to evaluate a patient's suicidal ideation and behavior) score performed by a nurse. The C-SSRS score was used to determine if a patient was low, moderate, or high risk (a yes answer on key questions within the assessment would increase the score from low to moderate or high risk). Interview revealed a medical provider would perform their assessment and their determination trumps the score of the nurse. Interview revealed the risk of self-harm was mitigated based on the patients' C-SSRS score, if a patient was Low risk, they were rounded on every fifteen minutes by the Rounder, if the patient was Moderate risk, they got a virtual sitter, and if the patient was High risk, they got a one-to-one sitter.

Interview on 11/27/2023 at 1504 with Nurse Vice President for ED Services #20 revealed the risk of self-harm were mitigated based on the patients' C-SSRS score. Interview revealed if a patient was Low risk, they were rounded on every fifteen minutes by the Rounder, if the patient was Moderate risk, they got a virtual sitter, and if the patient was High risk, they got a one-to-one sitter. The nurse would check on the patient as they deem appropriate and perform safety checks on every patient in the Pod every hour.

Interview on 11/28/2023 at 1306 with COO (Chief Operating Officer) #50 and ACNO #47 revealed nursing took safety steps for overflow areas of behavioral health patients in the Green and Purple Pods. The staff members reported that nursing checked off in the electronic medical record that they have validated the rooms were safe for the patient. The hospital saw an increase in the number of behavioral health patients, so when the new Pediatric ED area opened in September of 2023, the space that was previously used for pediatrics (identified as the Purple Pod) became an overflow/holding area for behavioral health patients. Interview revealed the last known time a medical ED patient was in the Purple Pod (a pediatric patient) was September 26, 2023 (after the environmental risk assessment for suicide prevention was performed on September 8, 2023). Interview revealed safety for behavioral health patients in the Green Pod based on their C-SSRS score would be every fifteen-minute check by the Rounder or the virtual sitter, or the one-to-one sitter. Depending on the volume of patients and their acuity (high risk, elopement risk, patients that wander) there would be either one or two Rounders in the Pod. Interview revealed if the volume was low, the hospital may need to and can put an adult patient in the Green Pod with the adolescent behavioral health patients. Interview revealed that based on the C-SSRS score, they would put in place mitigators (staff to monitor) to assure safety for patients. The staff member stated they do not monitor and cannot pull the data to determine the last time there were both pediatric/adolescent and adult patients in the Green Pod at the same time. Interview revealed the staff do not monitor when the Pods are used as behavioral health only patients versus medical ED patients, nor how frequently they are being flipped back and forth. It was reported that the staff mitigate the risk of harm in the room space down to what is deemed appropriate by removing trash cans, suction, cords, and make sure the beds have a behavioral health approved sheet on it. Interview revealed the corded call bell was not removed from the room as it is the patient's way of calling staff if they need something and it operates the television in the room. Mitigating factors (every fifteen-minute check, virtual sitter, or one-to-one sitter) are put in place based on the C-SSRS score. The staff member reported corded telephones are used if the patient wants to make a telephone call, and that it was a patient's right to make telephone calls. If the patient was high risk, have a one-to-one sitter with them when they have the telephone, if they were a moderate risk they have a virtual sitter with them, and the low risk has an every fifteen-minute check done by the Rounder. The "nurses are really in tune with the patients" in behavioral health. Interview revealed the nurses rotate throughout the ED and were not always working in the pods that have behavioral health only patients in them. Interview revealed the Green Pod and Purple Pods were not psych friendly. Mitigating factors were put in place such as every fifteen-minute check, virtual sitters, or one-to-one sitters based off the patients C-SSRS score.

Interview on 11/30/2023 at 1532 with Manager #51 and Manager #49, that performed the Suicide Risk Environmental Assessment on 09/08/2023, revealed the Green Pod and Purple Pod areas were a medical ED and not a Behavioral Health unit. Behavioral Health patients could be in any area of the ED. The staff reported that all risks for behavioral patients in the ED could be mitigated by every fifteen-minute observation, a virtual sitter, or a one-to-one sitter. The staff stated, the call bell cords break away from the wall if, for instance, someone pulled on it or put too much pressure on it. It was stated that they did not look at the cord itself as a risk used for hanging or self-harm, just that it could break away from the wall. Telephone cords were not evaluated on the risk assessment that was performed, and staff reported they were not aware that Behavioral Health patients were given a telephone with cords in their rooms. The interview revealed that a risk assessment was done for the entire ED on September 08, 2023. Interview revealed the staff conducting the assessment did not go in every room in the ED when they did the Environmental Risk Assessment for Suicidal Prevention. The staff members stated that they did not go back and look at the Purple Pod that was converted over to behavioral health holding/overflow after the pediatric patients were moved to the new pediatric ED.

Based on policy review, Quality Performance Improvement Plan review, medical record review, incident report reviews, pharmacy unit inspection review, and staff interviews, hospital leadership failed to ensure adverse events were documented, tracked, trended, and analyzed in order to implement preventive actions and identify success of actions taken.

The findings included:

1. The hospital staff failed to ensure tracking and trending of medical errors by failing to document incidents for improvement opportunities and failing to investigate potential causes and identify corrective action for seven (7) of 94 sampled patient records reviewed. (Patient #'s 58, 27, 59, 50, 15, 13, and 2).

Cross refer to §482.21 Standard: QAPI Quality Improvement Activities: Tag A 0286.

2. The hospital's leadership failed to provide oversight and responsibility of the quality improvement program to ensure medical errors were tracked and trended, failed to document incidents for improvement opportunities and failed to investigate potential causes and identify corrective action for 7 of 94 sampled patients reviewed. (Patient #'s 58, 27, 59, 50, 15, 13 and and 2).

Cross refer to §482.21 Standard: QAPI Quality Improvement Activities: Tag A 0309.

Based on policy review, medical record review, incident report review, pharmacy unit inspection review, personnel file review, hospital document review and staff and physician interviews, the hospital staff failed to ensure tracking and trending of medical errors by failing to document incidents for improvement opportunities and failing to investigate potential causes and identify corrective action for seven (7) of 94 sampled patients reviewed (Patient #'s 58, 27, 59, 50, 15, 13 and 2)

The findings included:

Review of the hospital policy titled "Event and Close Call Reporting" revised 10/13/2022 revealed "... Facility risk management personnel have the affirmative duty to oversee timely and thorough reporting within the designated systems ... Facility risk management personnel have the affirmative duty to oversee timely and thorough reporting within the designated systems... This policy applies to services provided by (Hospital Corporate Name) staff members in each of these settings: ... *Inpatient services, including acute care and behavioral health, critical access hospitals, and other related services * Emergency Departments (ED) * Hospital-based outpatient department or ambulatory services, including but not limited to behavioral health services and Independent Diagnostic Testing Facilities ... *Physician practices or clinics that may include rural health clinics or federally qualified health care centers ... NC Division Clarification ... In addition to the roles listed in the policy, the Directors of Quality and Patient Safety and/or Administrative Quality Directors are also responsible for oversight of this process ... Escalation to Leadership ..."

1. Medical record review revealed Patient #58 had a witnessed fall on 04/26/2023 following abdominal surgery for a gun shot wound. A CT (cat scan) of the Abdomen and Liver on 04/26/2023 showed changes to a liver hematoma (clotted blood within the tissues) from the previous CT study on 04/25/2023. Patient #58 was moved to ICU (intensive care unit) for closer monitoring, and Interventional Radiology was consulted to rule out active bleeding. On 04/27/2023 Patient #58's hemoglobin dropped from 13.2 to 7.3 [6.0] and he received 2 units of red blood cells, and he underwent CT Angiogram and found no active bleed.

Request for an event report on 12/05/2023 revealed there was not one available for Patient #58 after a witnessed fall, that required interventions.

Telephone interview on 12/06/2023 at 1332 with RN #95 revealed she remembered the patient. Interview revealed "...he said he was going to pass out. We assisted him back to the bed after the fall and called a rapid response. I called the doctor. I didn't remember to complete a report, it was not quite a fall. I guided him to the bed, and another nurse picked his legs up onto the bed..." Interview revealed Patient #58 had a witnessed fall, and an event report was not completed for Patient #58. Interview revealed hospital policy was not followed for Patient #58.

Interview on 12/06/2023 at 1409 with the Charge Nurse, RN #96 revealed "...if a patient falls, we complete a (named) an incident report..." Interview revealed for witnessed falls an incident report should be completed. Interview revealed an event report should have been completed for Patient #58. Interview revealed hospital policy was not followed for Patient #58.

Telephone interview on 12/07/2023 at 0906 with MD #94 revealed he remembered the patient. Interview revealed "...he had a traumatic liver injury it would not be surprising to have a re-bleed, it required packing, and hemorrhage control. He did get an CT and have an interventional radiology angiography procedure after the event to ensure he didn't have an active bleed...It's impossible to tell...the fall did not extend an injury or stay at the hospital..." Interview revealed Patient #58 did have interventions after the fall on 04/26/2023 to ensure he had no active bleeding. Interview revealed hospital policy was not followed for event reporting for Patient #58 after a witnessed fall.

2. Review on 12/05/2023 of the policy Facility Event and Close Call Reporting Policy and Procedure, with effective date 04/01/2022 revealed "...PURPOSE: This policy is intended to minimize risks to patients, ...through the development and implementation of an event and close call reporting system based upon the affirmative duty of all health care providers and all agents and employees of the licensed health care facility to report events and close calls to the Patient Safety Director, Risk Manager, or designee. Furthermore, this policy is intended to mitigate risks and improve quality of services by outlining the processes for factual reporting of events, close calls, and unsafe situations. POLICY: Facility staff will provide the needed data elements through a formal, documented event reporting system. Event reports should be completed as soon as possible after the event, but no later than the end of the shift...X. Fair and Accountable Reporting Culture...B. The responsibility for reporting an event or close call rests with any person who witnesses, discovers, or has direct knowledge of that event or close call..."

Medical record review revealed Patient #27 arrived in the ED on 07/04/2022 at 0025 with a reported abdominal pain level of 10 of 10, and nausea and vomiting. The patient had a STAT CT of the abdomen and pelvis ordered at 0027 that was not completed until 0755 (7 hours, 27 minutes later) resulted and signed at 0825. The patient had pain reported as 10 of 10, with nausea and vomiting with vital signs at arrival at 0025 and was not medicated with Dilaudid (narcotic pain medication) at 0739 (7 hours and 14 minutes after arrival). The patient was diagnosed with a small bowel obstruction and had surgery that day. The patient had a delay in pain management, STAT lab work, STAT CT, and physician orders as prescribed.

Request for a Patient Safety Report (Event Report) revealed there was not one available.

Interview on 11/15/2023 at 1350 with ED RN #38 who triaged Patient #27 revealed patients had delays in receiving pain management, STAT lab work and completion of physician orders in the ED waiting room. Interview revealed an event report was not completed for Patient #27.

Interview on 11/17/2023 at 1102 with NP #39 revealed she had current concerns with waiting room patients not getting orders completed in the ED waiting room. Interview revealed an incident report should have been completed for Patient #27.

Interview on 11/15/2023 at 1414 with ED MD #26 revealed "...I saw the patient after she was roomed.... There is not always a person to get labs and orders done. No staff to place orders. With the new process the goal is for that not to happen, but at night I suspect it does. As far as care in the waiting room, this patient didn't get vital signs, or overall assessments and no meds...things are not happening on a timely basis..." Interview revealed Patient #27 did not receive pain management, STAT lab work, STAT CT, and physician orders as prescribed. Interview revealed an incident report should have been completed for Patient #27.



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3. Closed medical record review revealed on 3/4/2023, Patient #59 was admitted to the oncology unit and received a diagnosis of acute myeloid leukemia. Per physician orders, treatment for acute myeloid leukemia included Dacogen (intravenous chemotherapy medication) and Venetoclax (oral oncology medication). On 3/17/2023, the patient was infused Dacogen after two (2) [oncology nurses] verified the medication. Further review revealed on 3/18/2023, an Oncologist documented that the patient received an expired dose of Dacogen.

The incident report for Patient #59's medication administration of the expired dose of Dacogen, was requested on 12/7/2023 at 11:00 AM from the Director of Quality. No incident report was provided.

Upon inquiry for pharmacy unit inspections from March 2023 through November 2023 revealed there had only been one inspection documented on 5/16/2023.

Interview on 12/6/2023 at approximately 8:45 AM with the oncology pharmacist revealed oncology patients could be located on any unit within the hospital, in which case, the oncology medication would be delivered from outpatient infusion pharmacy to the oncology unit. The oncology nurse(s) would be responsible for going to the perspective unit(s) for the administration (intravenous and/or oral) of the medication. The pharmacist was unaware that an oncology patient was administered an expired dose of Dacogen.

Interview on 12/7/2023 at approximately 10:30 AM with oncology staff revealed that Patient #59 declined the first dose of Dacogen, which could have resulted in the administration of an expired medication.

Interview on 12/7/2023 at 11:00 AM with the Director of Quality revealed the Oncologist failed to enter an incident report and/or failed to speak to anyone regarding the administration of an expired dose of Dacogen to Patient #59 that occurred 3/17/2023.

Interview on 12/7/2023 at 1:51 PM with the Oncology Unit Manager (OUM) revealed in April 2023 the oncology unit adopted a more detailed treatment administration checklist to assist the oncology nurses and the pharmacy department. The OUM further indicated she could not speak to the effectiveness of the updated checklist because no audits had been performed.

Telephone interview on 12/8/2023 at 3:00 PM with the Oncologist revealed providers were made aware after-the-fact of any problems or concerns. As related to the administration of expired medication to a patient, the oncologist revealed, efficacy should be the main concern which falls upon the pharmacy department and was pretty sure this was what happened in the case of Patient #59. Further inquiry revealed that since the hospital joined [name of organization], the oncology unit lost valuable nurses which led to the hiring of new/inexperienced staff, and increased use of travel staff. The changes in staff led to an increase in errors, especially with neutropenic patients, which resulted in a degradation in care. Additionally, in the past oncology patients were directly admitted to the oncology unit without emergency department presentation. Now, oncology patients were admitted through the emergency department secondary to closure of transfers, which put the oncology patients at an increased risk for infection. Additionally, the unit no longer admitted complex cases of oncology patients because those cases were referred to other hospitals. Further interview revealed pharmacy errors increased secondary to the loss of experienced oncologist pharmacists. The interview concluded with the aforementioned concerns were voiced to the Medical Director for the oncology service line in which there were no notifications or any observations of changes.


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4. Review of the closed medical record for Patient #50 revealed a 21-year-old female presented to the Emergency Department (ED) via law enforcement under IVC (involuntary commitment) for a "Psychiatric screening exam; Behavioral health concern." Review of the Provider Note dated 05/04/2023 at 1640 revealed "... patient presents with IVC paperwork and recent behavior concerning for danger to others in particular ... I will have behavioral health services see the patient ..." Review of the Initial Psychiatric Evaluation dated 05/06/2023 at 0531 revealed "The patient is a 21 yo (year old) female with h/o (history of) autism and mild intellectual disability, who was brought to the ED under IVC due to increasingly aggressive behavior. The IVC paperwork reports (sic) that the patient has been going around the neighborhood with a hammer. She has done thoughtless things such as covering her father's eyes with his hat while driving and then kicking him. The (sic) patient's behavior has been escalating since she could no longer participate in her programs during COVID 19 (pandemic). Instead of going to a group home, she was d/c (discharged) home from her last program. She has been increasingly irritable since she is swinging to calm herself down and has demonstarted (sic) dangerous behaviors ... Nursing reports pt (patient) became unexpectedly agitated this AM (morning), pulled nurse and sitter's hair after being asked if her ears hurt (she was pulling at them). She received 5 mg (milligrams) Versed (medication to help you relax) at time of arrival to the ED yesteay (sic) afternoon, but otherwise no PRN (as needed) medication. She has not required restraint ... She is mostly mute (refraining from speech), although sometimes echolalic (repeat others) and echopraxic (involuntary copying of another person's actions or movements). She waves when I wave. Says 'hello' when I say hello, and 'happy' when I ask if she is happy'(sic) ... Suggested plan; Uphold the IVC for now; observe the patient for the next 24-48 hours (sic); if the patient is stabilized, she can be discharged home or to a new placement, if one is available." Review of the Mental Health Contact Note dated 05/08/2023 at 1017 revealed "... reached out to Pt's mother, ..., and informed her that Pt was seen by Psychiatrist who is recommending discharge due to concerns of Pt safety on this unit, her aggressive behaviors w/ (with) other Pt's ..." Review of the Nurse Note dated 05/29/2023 at 0855 revealed "... This was the third time pt had attacked the hair of a sitter." Review of the Provider Note dated 05/29/2023 at 1007 revealed "...Patient was triggered by her sitter and attacked her this morning jumping on top of her and grabbing her hair ... Nursing staff reports this is the third sitter she is intact (sic) in the past 2 days ..." Review of the Nurse Note dated 06/10/2023 at 1920 revealed "Earlier today ... had multiple aggressive acts towards me, the first was when she spit on me as I was handing her a snack in the BHU (behavioral health unit) ... The second aggressive act came hours later when she saw me in the hall and came towards me. I attempted to walk away but she ran towards me, screaming and reaching for my face. She was able to pull the mask off my face but I restrained her hands and took several steps back, when she came after me again screaming and tearing at my head and face. I restrained her hands again and walked her back into her room towards her bed. As I let go and backed up ... leaned on her bed and kicked me in the chest with all her force ... I don't intend to escalate this matter any further and have explained the entire situation to the psych clinician." Mental Health Contact Note dated 06/18/2023 at 2100 revealed "... sitting in BHU intake office and heard yelling. Pt seen ... on camera gripping a male pt hair in ... hallway bed. Pt was standing over male pt's hallbed (sic), hand in male pt's hair shaking pt's head around. Male pt was yelling ... immediately came out of BHU intake office, pt ran back towards her room into her bed. Male pt was visibly upset and yelling at pt in her room ..." Nurse Note dated 06/18/2023 at 2130 revealed "Pt. ran out of her room and pulled hair/hit another pt who was in a hall bed. After getting loose the pt. ran after her back in to her room, a BERT (behavioral health emergency) was called, physician, RNs, psych clinicians, and security all responded. The pt who was attacked aggressively was shouting, punching the walls, and hitting her bed. We were able to de-escalate the situation and both pts. We moved the second pt. to a differed pod in his own room so he would feel safe. It is unsure if (Patient #50) was hit while he was hitting her bed, physician did an assessment and she has no obvious injuries or marks. Pts are both settled in separate areas now." Review of the medical record revealed Patient #50 was discharged to a facility on 06/20/2023 at 1659.

Review on 12/05/2023 of the incident/variance reports provided regarding Patient #50 revealed there were no incident/variance reports for the incident on 05/29/2023 nor on 06/10/2023 to correspond with the incidents described in the medical record notes. There were incidents dated 05/27/2023 and 06/18/2023.

Telephone interview on 12/06/2023 at 1400 with PSA #48 revealed she remembered Patient #50 and had to push her distress alarm button when caring for Patient #50. Interview revealed there had been several incidents involving Patient #50 pulling staff hair, attacking staff or other patients. Interview revealed PSA #18 had submitted incident/variance reports herself regarding more than one incident with Patient #50. Interview revealed there was a male patient in her room one time. PSA #18 could not remember the details about this incident, however confirmed she had filled out an incident report. PSA #18 stated there was a time when Patient #50 kissed another patient and an incident report should have been filled out about that.

Interview on 12/06/2023 at 1500 with Director #82 revealed she only had four incidents/variances for Patient #50. Three of the four were dated 2022 and only one from 2023. Director #82 did not have the incident/variance provided to this surveyor dated 05/27/2023. Interview revealed the person entering the incident/variance did not enter the medical record number and Director #20 searched by the medical record number. Interview revealed it is hard to find incidents/variances if the medical record number is not entered so the information will pull across the system and make it easier to find. Interview revealed they can search by name however if the name is misspelled there would be problems finding any incidents/variances that were entered. Director #82 requested more time to research to see if there were more incidents/variances. At time of exit from facility on 12/09/2023 at 1600, Director #82 had not provided any additional information to this surveyor regarding additional incidents/variances for Patient #50.



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5. Closed medical record review of Patient #15 revealed a 21 year old male admitted on 08/14/2023 with abdominal pain. Record review revealed the patient had laparoscopic converted to open total abdominal colectomy (remove all or part of colon) with end ileostomy (stoma-opening in abdomen surgically created) on 08/27/2023 for ulcerative colitis. Record review revealed on 08/27/2023 at 1117 a ketamine drip was ordered stat (urgent). Record review revealed the patient arrived in PACU (post anesthesia care unit) at 1120. Patient transferred to floor (unit) at 1420. Record review revealed ketamine was started at 1448 on the unit. Patient returned to PACU at 1515 for ketamine drip. Review of nursing note on 08/27/2023 at 1526 revealed "Ketamine gtt (drip) sent to floor from pharmacy rather than to PACU. Patient arrived on the unit from PACU without ketamine gtt started. Notified (named) CNC (clinical nurse coordinator) and called to PACU nurse for patient to be transferred back to PACU for ketamine gtt initiation and required monitoring." Review of nursing note on 08/27/2023 at 1656 revealed "Pt (patient) transferred to floor after report called to RN (registered nurse). PT was ordered Ketamine and the pharmacy sent the medication to the nursing unit instead of PACU. RN agreed in report to start ketamine on pt arrival to floor, since the ketamine was on the unit. Pt later brought back to pacu when nurse became aware that she was not cleared by hospital regulations to start the ketamine gtt."

Review of a ketamine drip timeline document revealed Ketamine drip ordered at 1117. The order was verified by pharmacy at 1140, but the label was not printed. Missing medication request sent by the RN at 1228, high priority with comment "please bring to PACU pod 2 bay 9". Medication request was accepted by pharmacy at 1243 and label was printed. Label stated A3W/A336 as location. Medication hand delivered to staff and signed as received by the named RN. Ketamine drip documented as initiated at 1448. Review of ketamine delivery signature sheet revealed no time of acceptance documented.

Review of the incident/variance reports provided regarding Patient #15 revealed there were no incident/variance reports for the incident on 08/27/2023 to correspond with the incident described in the medical record notes.

Interview on 11/16/2023 at 1045 with RPH #87 revealed medications are sent to locations based on the patient's location in the medical record. Interview revealed when patients are in PACU the pharmacy staff rely on nursing to put in a missing medication request in order to get the drug to the correct location.

Interview on 11/16/2023 at 1230 with PA #90 who ordered the drip revealed the drip was supposed to be initiated as soon as possible. Interview revealed the ketamine drip should have been started before the patient went to the floor. Interview revealed "the periop phase can be tricky and the patient's location does not populate automatically."

Interview on 11/16/2023 at 1421 with RN #88 revealed the PACU staff had waited for hours for the pharmacy to fill the order. Interview revealed the medication had been delivered to the floor and not to PACU. Interview revealed pharmacy was called several times to inquire about medication, "so we thought they knew that the patient was in PACU since we kept calling."

Interview on 11/17/2023 with NM #89 revealed ketamine drips are not done on the unit, they should be initiated on a higher level of care unit. Interview revealed the unit and pharmacy staff received education on which units can not initiate the ketamine drip. Interview revealed the education was in 12/2022. Interview revealed more education would be given to staff.

Interview on 11/27/2023 at 1540 with RPH #79 revealed the nursing staff would put in a medication request when they are ready for the medication to be prepared. The RN has to put in the location of the patient with the medication request. Interview revealed the pharmacy staff that processed the label may not be the same staff member that delivered the order, and the patient's location may not have been communicated to the delivery technician. Interview revealed the delivery technician would then go by the location that was printed on the label.

Request to interview a floor nurse revealed not available for interview.

Request to interview the unit CNC revealed not available for interview.



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6. Review of a policy titled "Physiologic Monitoring-Cardiac Telemetry Monitoring..." with a revision date of 08/14/2023, revealed "Internal (lateral) transfers within the (named hospital). C. Patients transferring to non-ICU (Intensive care unit) units with continuous ECG (Electrocardiogram) orders will transport on continuous ECG. 2. The receiving RN will notify CMU (cardiac monitoring unit) with patient name/MRN (medical record number), room being transferred to and telemetry box being assigned."

Closed medical review on of Patient #13 revealed a 76 year old male admitted on 08/19/2023 at 1430 for hypertension (high blood pressure) and Intracranial hemorrhage (brain bleed). Review of RN #53's note written on 08/25/2023 at 1750 revealed "Transferred to Floor. Transfer Report Given to (RN #54). Transport equipment: Monitor. Mode: Wheelchair." On 08/25/2023 at 1934, Patient #13 was transferred to a stepdown unit.
Review on 11/15/2023 of an incident report written by CMU supervisor #52 revealed (Patient #13)" had active 48 hr (hour) tele (telemetry) orders from 08.24.2023 at 1348 but were (sic) not being monitored." Review of telemetry strips failed to reveal a telemetry strip for evening hours of 08/25/2023. Review revealed Patient #13 was not monitored by telemetry for 6 hours.

Review of a Safety Event Timeline dated 08/29/2023 at 1408 from Manager #56 from Floor A revealed "Status: Assigned to Manager #55, Manager of Floor B (sending floor manager)." Review revealed on "08/31/2023 at 1234, Status: Assigned. Closed." Review revealed no further documentation from Manager #55. Review revealed no documentation of the investigation of the Patient #13 without telemetry monitoring.

Interview on 11/15/2023 at 1605 with CMU supervisor #52 revealed a daily audit is conducted at 0100 and 1300 of telemetry patients to ensure patients are being monitored as ordered. Interview revealed Patient #13 was found to have an order for telemetry but was not being monitored. Patient #13 had not been monitored since transfer to another floor on 08/25/2023 at 1934. Interview revealed Patient #13 was placed on telemetry on 08/26/2023 at 0139, 6 hours and 5 minutes after transfer to the floor.

Interview on 11/28/2023 at 1234 of RN #54 revealed no recollection of Patient #13 or details of the transfer. Interview revealed RN #54 had not been interviewed regarding the incident of Patient #13.

Interview on 11/28/2023 at 1633 of RN #53 revealed no recollection of Patient #13 or details of the transfer.

Interview on 11/30/2023 at 1645 with Risk Manager #58 revealed "incidents should be reviewed and escalated to the department leaders. There should be notes from the manager."

Interview of Manager #55 was not obtained due to no longer employed.

Patient #13 was transferred to Floor B with telemetry orders. After 6 hours, Patient #13 was discovered without telemetry. There was no review of the incident from the management of the sending floor or risk management.



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7. Medical record review on 11/14/2023 of Patient #2 revealed the patient arrived to the Emergency Department on 10/17/2023. Review of the EMS Patient Care Record revealed EMS received a call at 1654, arrived to Patient #2's home at 1720 and transported the patient to the hospital, arriving at 1748. EMS documented they transferred care of the patient to the hospital at 1907, 1 hour 19 minutes later. Prior to the transfer of care, review revealed EMS continued monitoring Patient #2. A note in the EMS record indicated "Turn Around Delays ....ED Overcrowding/ Transfer of Care. ..."

The hospital ED record review revealed the patient arrived at 1753 via EMS, with complaints of chest pain, shortness of breath, and syncope. Patient #2 was noted as evaluated by a provider at 1845 (52 minutes after arrival) and triaged by a RN at 1900 (1 hour, 7 minutes after arrival). An EKG was completed at 1905 (1 hour 12 minutes after arrival) and labs, including troponin, were drawn at 1920 (1 hour 27 minutes after arrival). Record review revealed a delay in the hospital accepting the patient from EMS, triaging and initiating care to the patient, including an EKG and labs. Patient #2 went into cardiac arrest at 1953 (2 hours after arrival) and subsequently expired after failed resuscitation attempts.

Review of a document received from the hospital related to this patient, on 11/16/2023, revealed it was not dated or timed and was not signed. Document review revealed the following statement: "I have reviewed this case and the initial presentation, the timing on the workup, the findings and escalation were all appropriate and met standard of care. The patient arrived at 1753, was roomed at 1830 and was seen by a clinician at 1845 the patient coded at 19:53 and had a time of death at 22024 (sic) all of which occurred while in a room. The EKG was reviewed by the initial clinician and reported in the chart. The patient coded at 1953 and Dr. (Name) was called to the Code. During the code Dr. (Name) has documented that the patient had brief return of consciousness with the ongoing CPR. During this time he began reviewing the workup and the EKG, which was handed to him at 2002. It was read as sinus rhythm with a PVC and a 4 beat run of non-sustained ventricular tachycardia. He signed this EKG at this time 2002, the code was continued for another 22 minutes before time of death." There were no other notations on the received document including no identification of who completed it or when. The document did not identify any areas of concern. There was no documented review of the timing of triage or implementation of orders. Additional information on the document was requested on 11/17/2023. No updated information was received.

Telephone interview on 11/20/2023 at 1415 with EMS #70 revealed EMS was able to given hand-off report to a nurse at 1907 (over an hour after arrival). Interview revealed wait times for EMS to hand-off patients had recently gotten more common.

Telephone interview with RN #66, on 11/16/2023 at 0938, revealed that until patients were in a room and care handed-off from EMS, they were "counting on EMS to care for (the patients). ..."

Telephone interview with PA #71, on 11/15/2023 at 1600, revealed the goal for screening evaluations was 20 minutes from arrival.

Telephone interview on 11/16/2023 at 1100 with MD #72 revealed the expectation for chest pain patients was an EKG within 10 minutes and to be seen by a provider within 10 minutes. MD #72 acknowledged a delay with Patient #2. Interview revealed the physician was not aware if there was a review of the case.

Review of documents received did not reveal an incident report. Review of findings and document provided revealed the hospital failed to identify and evaluate delays in accepting, triaging and initiating care and treatment for a patient presenting via EMS with chest pain.

Based on policy review, Quality Improvement Performance Plan review, medical record review, incident report review, pharmacy unit inspection review, personnel file review, hospital document review and staff and physician interviews, the hospital's leadership failed to provide oversight and responsibility of the quality improvement program to ensure medical errors were tracked and trended, failed to document incidents for improvement opportunities and failed to investigate potential causes and identify corrective action for seven (7) of 94 sampled patients reviewed (Patient#'s 58, 27, 59, 50, 15, 13 and 2).

The findings included:

Review of the Quality Improvement Plan approved by the hospital Chief Executive Officer (CEO), Board of Trustees Chair and Chief Medical Officer (CMO) on 04/24/2023 revealed, " ...The hospital-wide Performance Improvement Plan is designed to improve quality performance and patient safety, ultimately reducing the risk to patients. ... ACCOUNTABILITY ... The following individual and/or committees are accountable for setting expectations, developing plans, and implementing procedures to assess, improve quality, and measure performance improvement within the organization. ... Board of Trustees ... The Board of Trustees delegates the responsibility for implementing this plan to the Medical Staff, through its Medical Staff committees and the hospital through its Quality, patient safety, and Performance Improvement Committees and leadership team. ... The (hospital name) Quality Council was organized as an interdisciplinary team with representation of Department Directors/Managers, hospital leadership, and key staff members with input from the Chief Medical Officer. The functions of the committee include but are not limited to: ... 2. Review data including continuous measurement activities of important functions. 3. Identify of (sic) problems/opportunities for improvement. 4. Review of actions planned or completed. 5. Evaluate of (sic) the effectiveness of actions completed. ... Staff will be accountable to: 1. Detect adverse events and near-misses. 2. Report events or near-misses via the incident reporting system. 3. Comply with all policies and procedures to mitigate risk and loss to the facility. ... Aggregation and analysis of performance data is used to compare internal performance with industry standards, comparable organizations, and best practices. ... Data is collected in a systemic manner to: a Establish a performance baseline and compare to national benchmarks ... d) Identify areas of opportunity for more focused data abstraction/reviews ... Data analysis is performed to identify processes to be targeted for change or improvement. The intent is to reduce the probability of adverse outcomes and eliminate patient harm events. The following events or outcomes require data analysis: ... b) Performance measurements that reveal significant undesirable variation from recognized standards ...h) Patterns of frequent event reporting (i.e. patient injury, including near misses) ... Patient Safety/ Risk Management is responsible for ensuring a culture of safety while promoting safe, error-free care, and a safe environment for our patients, staff and visitors. Patient Safety/ Risk Management works collaboratively with hospital personnel as they review and triage all reported events and create detailed analysis of the causes of events. ..."

Review of the hospital policy titled "Event and Close Call Reporting" revised 10/13/2022 revealed "... Facility risk management personnel have the affirmative duty to oversee timely and thorough reporting within the designated systems ... Facility risk management personnel have the affirmative duty to oversee timely and thorough reporting within the designated systems... This policy applies to services provided by (Hospital Corporate Name) staff members in each of these settings: ... *Inpatient services, including acute care and behavioral health, critical access hospitals, and other related services * Emergency Departments (ED) * Hospital-based outpatient department or ambulatory services, including but not limited to behavioral health services and Independent Diagnostic Testing Facilities ... *Physician practices or clinics that may include rural health clinics or federally qualified health care centers ... NC Division Clarification ... In addition to the roles listed in the policy, the Directors of Quality and Patient Safety and/or Administrative Quality Directors are also responsible for oversight of this process ... Escalation to Leadership ..."

1. Medical record review revealed Patient #58 had a witnessed fall on 04/26/2023 following abdominal surgery for a gun shot wound. A CT (cat scan) of the Abdomen and Liver on 04/26/2023 showed changes to a liver hematoma (clotted blood within the tissues) from the previous CT study on 04/25/2023. Patient #58 was moved to ICU (intensive care unit) for closer monitoring, and Interventional Radiology was consulted to rule out active bleeding. On 04/27/2023 Patient #58's hemoglobin dropped from 13.2 to 7.3 [6.0] and he received 2 units of red blood cells, and he underwent CT Angiogram and found no active bleed.

Request for an event report on 12/05/2023 revealed there was not one available for Patient #58 after a witnessed fall, that required interventions.

Telephone interview on 12/06/2023 at 1332 with RN #95 revealed she remembered the patient. Interview revealed "...he said he was going to pass out. We assisted him back to the bed after the fall and called a rapid response. I called the doctor. I didn't remember to complete a report, it was not quite a fall. I guided him to the bed, and another nurse picked his legs up onto the bed..." Interview revealed Patient #58 had a witnessed fall, and an event report was not completed for Patient #58. Interview revealed hospital policy was not followed for Patient #58.

Interview on 12/06/2023 at 1409 with the Charge Nurse, RN #96 revealed "...if a patient falls, we complete a (named) an incident report..." Interview revealed for witnessed falls an incident report should be completed. Interview revealed an event report should have been completed for Patient #58. Interview revealed hospital policy was not followed for Patient #58.

Telephone interview on 12/07/2023 at 0906 with MD #94 revealed he remembered the patient. Interview revealed "...he had a traumatic liver injury it would not be surprising to have a rebleed, it required packing, and hemorrhage control. He did get an CT and have an interventional radiology angiography procedure after the event to ensure he didn't have an active bleed...It's impossible to tell...the fall did not extend an injury or stay at the hospital..." Interview revealed Patient #58 did have interventions after the fall on 04/26/2023 to ensure he had no active bleeding. Interview revealed hospital policy was not followed for event reporting for Patient #58 after a witnessed fall.

2. Review on 12/05/2023 of the policy Facility Event and Close Call Reporting Policy and Procedure, with effective date 04/01/2022 revealed "...PURPOSE: This policy is intended to minimize risks to patients, ...through the development and implementation of an event and close call reporting system based upon the affirmative duty of all health care providers and all agents and employees of the licensed health care facility to report events and close calls to the Patient Safety Director, Risk Manager, or designee. Furthermore, this policy is intended to mitigate risks and improve quality of services by outlining the processes for factual reporting of events, close calls, and unsafe situations. POLICY: Facility staff will provide the needed data elements through a formal, documented event reporting system. Event reports should be completed as soon as possible after the event, but no later than the end of the shift...X. Fair and Accountable Reporting Culture...B. The responsibility for reporting an event or close call rests with any person who witnesses, discovers, or has direct knowledge of that event or close call..."

Medical record review revealed Patient #27 arrived in the ED on 07/04/2022 at 0025 with a reported abdominal pain level of 10 of 10, and nausea and vomiting. The patient had a STAT CT of the abdomen and pelvis ordered at 0027 that was not completed until 0755 (7 hours, 27 minutes later) resulted and signed at 0825. The patient had pain reported as 10 of 10, with nausea and vomiting with vital signs at arrival at 0025 and was not medicated with Dilaudid (narcotic pain medication) at 0739 (7 hours and 14 minutes after arrival). The patient was diagnosed with a small bowel obstruction and had surgery that day. The patient had a delay in pain management, STAT lab work, STAT CT, and physician orders as prescribed.

Request for a Patient Safety Report (Event Report) revealed there was not one available.

Interview on 11/15/2023 at 1350 with ED RN #38 who triaged Patient #27 revealed patients had delays in receiving pain management, STAT lab work and completion of physician orders in the ED waiting room. Interview revealed an event report was not completed for Patient #27.

Interview on 11/17/2023 at 1102 with NP #39 revealed she had current concerns with waiting room patients not getting orders completed in the ED waiting room. Interview revealed an incident report should have been completed for Patient #27.

Interview on 11/15/2023 at 1414 with ED MD #26 revealed "...I saw the patient after she was roomed.... There is not always a person to get labs and orders done. No staff to place orders. With the new process the goal is for that not to happen, but at night I suspect it does. As far as care in the waiting room, this patient didn't get vital signs, or overall assessments and no meds...things are not happening on a timely basis..." Interview revealed Patient #27 did not receive pain management, STAT lab work, STAT CT, and physician orders as prescribed. Interview revealed an incident report should have been completed for Patient #27.



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3. Closed medical record review revealed on 3/4/2023, Patient #59 was admitted to the oncology unit and received a diagnosis of acute myeloid leukemia. Per physician orders, treatment for acute myeloid leukemia included Dacogen (intravenous chemotherapy medication) and Venetoclax (oral oncology medication). On 3/17/2023, the patient was infused Dacogen after two (2) [oncology nurses] verified the medication. Further review revealed on 3/18/2023, an Oncologist documented that the patient received an expired dose of Dacogen.

The incident report for Patient #59's medication administration of the expired dose of Dacogen, was requested on 12/7/2023 at 11:00 AM from the Director of Quality. No incident report was provided.

Upon inquiry for pharmacy unit inspections from March 2023 through November 2023 revealed there had only been one inspection documented on 5/16/2023.

Interview on 12/6/2023 at approximately 8:45 AM with the oncology pharmacist revealed oncology patients could be located on any unit within the hospital, in which case, the oncology medication would be delivered from outpatient infusion pharmacy to the oncology unit. The oncology nurse(s) would be responsible for going to the perspective unit(s) for the administration (intravenous and/or oral) of the medication. The pharmacist was unaware that an oncology patient was administered an expired dose of Dacogen.

Interview on 12/7/2023 at approximately 10:30 AM with oncology staff revealed that Patient #59 declined the first dose of Dacogen, which could have resulted in the administration of an expired medication.

Interview on 12/7/2023 at 11:00 AM with the Director of Quality revealed the Oncologist failed to enter an incident report and/or failed to speak to anyone regarding the administration of an expired dose of Dacogen to Patient #59 that occurred 3/17/2023.

Interview on 12/7/2023 at 1:51 PM with the Oncology Unit Manager (OUM) revealed in April 2023 the oncology unit adopted a more detailed treatment administration checklist to assist the oncology nurses and the pharmacy department. The OUM further indicated she could not speak to the effectiveness of the updated checklist because no audits had been performed.

Telephone interview on 12/8/2023 at 3:00 PM with the Oncologist revealed providers were made aware after-the-fact of any problems or concerns. As related to the administration of expired medication to a patient, the oncologist revealed, efficacy should be the main concern which falls upon the pharmacy department and was pretty sure this was what happened in the case of Patient #59. Further inquiry revealed that since the hospital joined [name of organization], the oncology unit lost valuable nurses which led to the hiring of new/inexperienced staff, and increased use of travel staff. The changes in staff led to an increase in errors, especially with neutropenic patients, which resulted in a degradation in care. Additionally, in the past oncology patients were directly admitted to the oncology unit without emergency department presentation. Now, oncology patients were admitted through the emergency department secondary to closure of transfers, which put the oncology patients at an increased risk for infection. Additionally, the unit no longer admitted complex cases of oncology patients because those cases were referred to other hospitals. Further interview revealed pharmacy errors increased secondary to the loss of experienced oncologist pharmacists. The interview concluded with the aforementioned concerns were voiced to the Medical Director for the oncology service line in which there were no notifications or any observations of changes.


40299

4. Review of the closed medical record for Patient #50 revealed a 21-year-old female presented to the Emergency Department (ED) via law enforcement under IVC (involuntary commitment) for a "Psychiatric screening exam; Behavioral health concern." Review of the Provider Note dated 05/04/2023 at 1640 revealed "... patient presents with IVC paperwork and recent behavior concerning for danger to others in particular ... I will have behavioral health services see the patient ..." Review of the Initial Psychiatric Evaluation dated 05/06/2023 at 0531 revealed "The patient is a 21 yo (year old) female with h/o (history of) autism and mild intellectual disability, who was brought to the ED under VC due to increasingly aggressive behavior. The IVC paperwork reports (sic) that the patient has been going around the neighborhood with a hammer. She has done thoughtless things such as covering her father's eyes with his hat while driving and then kicking him. THe (sic) patient's behavior has been escalating since she could no longer participate in her programs during COVID 19 (pandemic). Instead of going to a group home, she was d/c (discharged) home from her last program. She has been increasingly irritable since she is swinging to calm herself down and has demonstarted (sic) dangerous behaviors ... Nursing reports pt (patient) became unexpectedly agitated this AM (morning), pulled nurse and sitter's hair after being asked if her ears hurt (she was pulling at them). She received 5 mg (milligrams) Versed (medication to help you relax) at time of arrival to the ED yesteay (sic) afternoon, but otherwise no PRN (as needed) medication. She has not required restraint ... She is mostly mute (refraining from speech), although sometimes echolalic (repeat others) and echopraxic (involuntary copying of another person's actions or movements). She waves when I wave. Says 'hello' when I say hello, and 'happy' when I ask if she is happy'(sic) ... Suggested plan; Uphold the IVC for now; observe the patient for the next 24-48 hours (sic); if the patient is stabilized, she can be discharged home or to a new placement, if one is available." Review of the Mental Health Contact Note dated 05/08/2023 at 1017 revealed "... reached out to Pt's mother, ..., and informed her that Pt was seen by Psychiatrist who is recommending discharge due to concerns of Pt safety on this unit, her aggressive behaviors w/ (with) other Pt's ..." Review of the Nurse Note dated 05/29/2023 at 0855 revealed "... This was the third time pt had attacked the hair of a sitter." Review of the Provider Note dated 05/29/2023 at 1007 revealed "...Patient was triggered by her sitter and attacked her this morning jumping on top of her and grabbing her hair ... Nursing staff reports this is the third sitter she is intact (sic) in the past 2 days ..." Review of the Nurse Note dated 06/10/2023 at 1920 revealed "Earlier today ... had multiple aggressive acts towards me, the first was when she spit on me as I was handing her a snack in the BHU (behavioral health unit) ... The second aggressive act came hours later when she saw me in the hall and came towards me. I attempted to walk away but she ran towards me, screaming and reaching for my face. She was able to pull the mask off my face but I restrained her hands and took several steps back, when she came after me again screaming and tearing at my head and face. I restrained her hands again and walked her back into her room towards her bed. As I let go and backed up ... leaned on her bed and kicked me in the chest with all her force ... I don't intend to escalate this matter any further and have explained the entire situation to the psych clinician." Mental Health Contact Note dated 06/18/2023 at 2100 revealed "... sitting in BHU intake office and heard yelling. Pt seen ... on camera gripping a male pt hair in ... hallway bed. Pt was standing over male pt's hallbed (sic), hand in male pt's hair shaking pt's head around. Male pt was yelling ... immediately came out of BHU intake office, pt ran back towards her room into her bed. Male pt was visibly upset and yelling at pt in her room ..." Nurse Note dated 06/18/2023 at 2130 revealed "Pt. ran out of her room and pulled hair/hit another pt who was in a hall bed. After getting loose the pt. ran after her back in to her room, a BERT (behavioral health emergency) was called, physician, RNs, psych clinicians, and security all responded. The pt who was attacked aggressively was shouting, punching the walls, and hitting her bed. We were able to de-escalate the situation and both pts. We moved the second pt. to a differed pod in his own room so he would feel safe. It is unsure if (Patient #50) was hit while he was hitting her bed, physician did an assessment and she has no obvious injuries or marks. Pts are both settled in separate areas now." Review of the medical record revealed Patient #50 was discharged to a facility on 06/20/2023 at 1659.

Review on 12/05/2023 of the incident/variance reports provided regarding Patient #50 revealed there were no incident/variance reports for the incident on 05/29/2023 nor on 06/10/2023 to correspond with the incidents described in the medical record notes. There were incidents dated 05/27/2023 and 06/18/2023.

Telephone interview on 12/06/2023 at 1400 with PSA #48 revealed she remembered Patient #50 and had to push her distress alarm button when caring for Patient #50. Interview revealed there had been several incidents involving Patient #50 pulling staff hair, attacking staff or other patients. Interview revealed PSA #18 had submitted incident/variance reports herself regarding more than one incident with Patient #50. Interview revealed there was a male patient in her room one time. PSA #18 could not remember the details about this incident, however confirmed she had filled out an incident report. PSA #18 stated there was a time when Patient #50 kissed another patient and an incident report should have been filled out about that.

Interview on 12/06/2023 at 1500 with Director #82 revealed she only had four incidents/variances for Patient #50. Three of the four were dated 2022 and only one from 2023. Director #82 did not have the incident/variance provided to this surveyor dated 05/27/2023. Interview revealed the person entering the incident/variance did not enter the medical record number and Director #20 searched by the medical record number. Interview revealed it is hard to find incidents/variances if the medical record number is not entered so the information will pull across the system and make it easier to find. Interview revealed they can search by name however if the name is misspelled there would be problems finding any incidents/variances that were entered. Director #82 requested more time to research to see if there were more incidents/variances. At time of exit from facility on 12/09/2023 at 1600, Director #82 had not provided any additional information to this surveyor regarding additional incidents/variances for Patient #50.



47421

5. Closed medical record review of Patient #15 revealed a 21 year old male admitted on 08/14/2023 with abdominal pain. Record review revealed the patient had laparoscopic converted to open total abdominal colectomy (remove all or part of colon) with end ileostomy (stoma-opening in abdomen surgically created) on 08/27/2023 for ulcerative colitis. Record review revealed on 08/27/2023 at 1117 a ketamine drip was ordered stat (urgent). Record review revealed the patient arrived in PACU (post anesthesia care unit) at 1120. Patient transferred to floor (unit) at 1420. Record review revealed ketamine was started at 1448 on the unit. Patient returned to PACU at 1515 for ketamine drip. Review of nursing note on 08/27/2023 at 1526 revealed "Ketamine gtt (drip) sent to floor from pharmacy rather than to PACU. Patient arrived on the unit from PACU without ketamine gtt started. Notified (named) CNC (clinical nurse coordinator) and called to PACU nurse for patient to be transferred back to PACU for ketamine gtt initiation and required monitoring." Review of nursing note on 08/27/2023 at 1656 revealed "Pt (patient) transferred to floor after report called to RN (registered nurse). PT was ordered Ketamine and the pharmacy sent the medication to the nursing unit instead of PACU. RN agreed in report to start ketamine on pt arrival to floor, since the ketamine was on the unit. Pt later brought back to pacu when nurse became aware that she was not cleared by hospital regulations to start the ketamine gtt."

Review of a ketamine drip timeline document revealed Ketamine drip ordered at 1117. The order was verified by pharmacy at 1140, but the label was not printed. Missing medication request sent by the RN at 1228, high priority with comment "please bring to PACU pod 2 bay 9". Medication request was accepted by pharmacy at 1243 and label was printed. Label stated A3W/A336 as location. Medication hand delivered to staff and signed as received by the named RN. Ketamine drip documented as initiated at 1448. Review of ketamine delivery signature sheet revealed no time of acceptance documented.

Review of the incident/variance reports provided regarding Patient #15 revealed there were no incident/variance reports for the incident on 08/27/2023 to correspond with the incident described in the medical record notes.

Interview on 11/16/2023 at 1045 with RPH #87 revealed medications are sent to locations based on the patient's location in the medical record. Interview revealed when patients are in PACU the pharmacy staff rely on nursing to put in a missing medication request in order to get the drug to the correct location.

Interview on 11/16/2023 at 1230 with PA #90 who ordered the drip revealed the drip was supposed to be initiated as soon as possible. Interview revealed the ketamine drip should have been started before the patient went to the floor. Interview revealed "the periop phase can be tricky and the patient's location does not populate automatically."

Interview on 11/16/2023 at 1421 with RN #88 revealed the PACU staff had waited for hours for the pharmacy to fill the order. Interview revealed the medication had been delivered to the floor and not to PACU. Interview revealed pharmacy was called several times to inquire about medication, "So we thought they knew that the patient was in PACU since we kept calling."

Interview on 11/17/2023 with Nurse Manager (NM) #89 revealed ketamine drips are not done on the unit, they should be initiated on a higher level of care unit. Interview revealed the unit and pharmacy staff received education on which units can not initiate the ketamine drip. Interview revealed the education was in 12/2022. Interview revealed more education would be given to staff.

Interview on 11/27/2023 at 1540 with RPH #79 revealed the nursing staff would put in a medication request when they are ready for the medication to be prepared. The RN has to put in the location of the patient with the medication request. Interview revealed the pharmacy staff that processed the label may not be the same staff member that delivered the order, and the patient's location may not have been communicated to the delivery technician. Interview revealed the delivery technician would then go by the location that was printed on the label.

Request to interview a floor nurse revealed not available for interview.

Request to interview the unit CNC revealed not available for interview.




34065

6. Review of a policy titled "Physiologic Monitoring-Cardiac Telemetry Monitoring..." with a revision date of 08/14/2023, revealed "Internal (lateral) transfers within the (named hospital). C. Patients transferring to non-ICU (Intensive care unit) units with continuous ECG (Electrocardiogram) orders will transport on continuous ECG. 2. The receiving RN will notify CMU (cardiac monitoring unit) with patient name/MRN (medical record number), room being transferred to and telemetry box being assigned."

Closed medical review on of Patient #13 revealed a 76 year old male admitted on 08/19/2023 at 1430 for hypertension (high blood pressure) and Intracranial hemorrhage (brain bleed). Review of RN #53's note written on 08/25/2023 at 1750 revealed "Transferred to Floor. Transfer Report Given to (RN #54). Transport equipment: Monitor. Mode: Wheelchair." On 08/25/2023 at 1934, Patient #13 was transferred to a stepdown unit.
Review on 11/15/2023 of an incident report written by CMU supervisor #52 revealed (Patient #13)" had active 48 hr (hour) tele (telemetry) orders from 08.24.2023 at 1348 but were (sic) not being monitored." Review of telemetry strips failed to reveal a telemetry strip for evening hours of 08/25/2023. Review revealed Patient #13 was not monitored by telemetry for 6 hours.

Review of a Safety Event Timeline dated 08/29/2023 at 1408 from Manager #56 from Floor A revealed "Status: Assigned to Manager #55, Manager of Floor B (sending floor manager)." Review revealed on "08/31/2023 at 1234, Status: Assigned. Closed." Review revealed no further documentation from Manager #55. Review revealed no documentation of the investigation of the Patient #13 without telemetry monitoring.

Interview on 11/15/2023 at 1605 with CMU supervisor #52 revealed a daily audit is conducted at 0100 and 1300 of telemetry patients to ensure patients are being monitored as ordered. Interview revealed Patient #13 was found to have an order for telemetry but was not being monitored. Patient #13 had not been monitored since transfer to another floor on 08/25/2023 at 1934. Interview revealed Patient #13 was placed on telemetry on 08/26/2023 at 0139, 6 hours and 5 minutes after transfer to the floor.

Interview on 11/28/2023 at 1234 of RN #54 revealed no recollection of Patient #13 or details of the transfer. Interview revealed RN #54 had not been interviewed regarding the incident of Patient #13.

Interview on 11/28/2023 at 1633 of RN #53 revealed no recollection of Patient #13 or details of the transfer.

Interview on 11/30/2023 at 1645 with Risk Manager #58 revealed "incidents should be reviewed and escalated to the department leaders. There should be notes from the manager."

Interview of Manager #55 was not obtained due to no longer employed.

In summary, Patient #13 was transferred to Floor B with telemetry orders. After 6 hours, Patient #13 was discovered without telemetry. There was no review of the incident from the management of the sending floor or risk management.



33790

7. Medical record review on 11/14/2023 of Patient #2 revealed the patient arrived to the Emergency Department (ED) on 10/17/2023. Review of the EMS Patient Care Record revealed EMS received a call at 1654, arrived to Patient #2's home at 1720 and transported the patient to the hospital, arriving at 1748. EMS documented they transferred care of the patient to the hospital at 1907, 1 hour 19 minutes later. Prior to the transfer of care, review revealed EMS continued monitoring Patient #2. A note in the EMS record indicated "Turn Around Delays ....ED Overcrowding/ Transfer of Care. ..."

The hospital emergency department record review revealed the patient arrived at 1753 via EMS, with complaints of chest pain, shortness of breath, and syncope. Patient #2 was noted as evaluated by a provider at 1845 (52 minutes after arrival) and triaged by a RN at 1900 (1 hour, 7 minutes after arrival). An EKG was completed at 1905 (1 hour 12 minutes after arrival) and labs, including troponin, were drawn at 1920 (1 hour 27 minutes after arrival). Record review revealed a delay in the hospital accepting the patient from EMS, triaging and initiating care to the patient, including an EKG and labs. Patient #2 went into cardiac arrest at 1953 (2 hours after arrival) and subsequently expired after failed resuscitation attempts.

Review of a document received from the hospital related to this patient, on 11/16/2023, revealed it was not dated or timed and was not signed. Document review revealed the following statement: "I have reviewed this case and the initial presentation, the timing on the workup, the findings and escalation were all appropriate and met standard of care. The patient arrived at 1753, was roomed at 1830 and was seen by a clinician at 1845 the patient coded at 19:53 and had a time of death at 22024 (sic) all of which occurred while in a room. The EKG was reviewed by the initial clinician and reported in the chart. The patient coded at 1953 and Dr. (Name) was called to the Code. During the code Dr. (Name) has documented that the patient had brief return of consciousness with the ongoing CPR. During this time he began reviewing the workup and the EKG, which was handed to him at 2002. It was read as sinus rhythm with a PVC and a 4 beat run of non-sustained ventricular tachycardia. He signed this EKG at this time 2002, the code was continued for another 22 minutes before time of death." There were no other notations on the received document including no identification of who completed it or when. The document did not identify any areas of concern. There was no documented review of the timing of triage or implementation of orders. Additional information on the document was requested on 11/17/2023. No updated information was received.

Telephone interview on 11/20/2023 at 1415 with EMS #70 revealed EMS was able to give hand-off report to a nurse at 1907 (over an hour after arrival). Interview revealed wait times for EMS to hand-off patients had recently gotten more common.

Telephone interview with RN #66, on 11/16/2023 at 0938, revealed that until patients were in a room and care handed-off from EMS, they were "counting on EMS to care for (the patients). ..."

Telephone interview with PA #71, on 11/15/2023 at 1600, revealed the goal for screening evaluations was 20 minutes from arrival.

Telephone interview on 11/16/2023 at 1100 with MD #72 revealed the expectation for chest pain patients was an EKG within 10 minutes and to be seen by a provider within 10 minutes. MD #72 acknowledged a delay with Patient #2. Interview revealed the physician was not aware if there was a review of the case.

Review of documents received did not reveal an incident report. Review of findings and document provided revealed the hospital failed to identify and evaluate delays in accepting, triaging and initiating care and treatment for a patient presenting via EMS with chest pain.

Based on policy review, medical record review, incident report review, EMS trip report review, and staff and provider interviews, the hospital's nursing staff failed to have an effective nursing service providing oversight of day to day operations by failing to ensure systems were in place to supervise and provide safe delivery of care to patients presenting to the emergency department (ED).

The findings included:

1. The hospital's emergency department staff failed to ensure adequate nursing staff was available to provide and monitor the delivery of assessments, care, and treatments in the emergency department for 4 of 35 sampled ED records reviewed (Patient #'s 28, 43, 27, and 2).

Cross refer to 482.23 Nursing Standard: Tag A 0392.

1. The hospital nursing leadership staff failed to ensure policies were implemented to evaluate, monitor and provide treatment for patients presenting to the emergency department resulting in delays and lack of triage, nursing assessment, monitoring, and implementation of lab, telemetry, medication and treatment orders for 11 of 35 ED records reviewed (Patient #'s 92, 83, 43, 28, 27, 29, 6, 1, 2, 12 and 26).

Cross refer to 482.23 Nursing Standard: Tag A 0398.

2. The hospital nursing staff failed to administer medications and biologicals according to provider orders and standards of practice by failing to administer medications as ordered and evaluate and monitor the effects of the medication for six (6) of 35 patients presenting to the emergency department (Patient #'s 92, 83, 43, 28, 27, and 26).

Cross refer to 482.23 Nursing Standard: Tag A 0405.

Based on policy, medical record review, incident report review, and staff and provider interviews, the hospital's emergency department staff failed to ensure adequate nursing staff was available to provide and monitor the delivery of assessments, care, and treatments in the Emergency Department (ED) for eleven (11) of 35 patient records reviewed (Patient #'s 92, 83, 43, 28, 27, 29, 6, 1, 2, 12 and 26).

The findings included:

Cross refer to §482.55 Emergency Services Standard: Tag 1101.

The ED nursing staff failed to ensure emergency care and services were provided according to policy and provider orders. Patients were not accepted upon arrival to the ED, evaluated, monitored and provided treatment to prevent delays and/or lack of triage, nursing assessment, and implementation of orders, including lab, telemetry and medication orders Patient #'s 92, 83, 43, 28, 27, 29, 6, 1, 2, 12 and 26.

1. Patient #92 presented to the ED with chest pain on 11/09/2023 at 1149. The patient was not assessed by a nurse after triage was completed at 1155, or with a change in condition, or after pain medication was administered at 1703. The patient was never placed on continuous telemetry in the ED as ordered by a physician at 1218. The patient was transferred to a medical floor and placed on telemetry at 2111 when he was found to be in atrial fibrillation with rapid ventricular rate, prompting a STEMI Code Activation. The patient underwent an emergency cardiac catheterization at 2249. ED nursing staff failed to provide ongoing assessment of the patient's condition and follow physician's orders for application of continuous telemetry. Nursing staff failed to ensure policies and provider orders were implemented.

2. Patient #83 was presented to the ED with dizziness on 11/28/2023 at 1216. The patient had STAT (immediate) lab work ordered at 1218 with continuous ECG monitoring. Labs were drawn at 1358 (1 hour and 40 minutes after ordered). Labs arrived at the lab at 1412 and resulted at 1532 (3 hours and 14 minutes after ordered). The blood glucose was 1137 (critically high). Insulin IV infusion was ordered at 1626 and initiated at 1709 (1 hour and 13 minutes after ordered and 1 hour and 37 minutes after the glucose resulted). Orders for continuous ECG monitoring placed at 1218, and vital signs every 2 hours were never initiated in the ED. At 2349 an IV infusion of D51/2 KCL was ordered that was not completed until 0157 (2 hours. and 8 minutes after ordered). Lactic acid was ordered NOW at 0127 for nurse collect in the ED. At 0200 a physician wrote there was a delay in labs and fluids so stopped the insulin IV infusion. The lactic acid was not collected in the ED. At 0529 the original lactic acid NOW, order was cancelled and reordered as lab collect NOW on the floor. It was collected at 0844 (3 hours and 15 minutes after ordered at 0529) and resulted at 1108 (9 hours and 41 minutes after originally ordered at 0127) with a result of 7.48 critical high. A second lactic acid was reordered at 1108 and resulted at 1256 (1 hr. and 36 minutes after ordered) with a result of 11.96 critically high. A rapid response was called previously at 1158, the patient was intubated at 1247, and ultimately expired on 11/30/2023.

3. Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of chest pain, nausea, clammy, lightheaded, right-side tingling for several weeks, with a reported history of drinks 12 beers a day. Review revealed the patient was located in the waiting room area and was observed by a physician to be diaphoretic. The physician ordered intravenous (IV) fluids and CIWA protocol (assessment tool used for alcohol withdrawal) at 1841, and Ativan (medication for anxiety) was ordered at 1947. These orders were not implemented. Multivitamin was ordered at 2100. Another order was placed at 2226 for IV fluids and Lopressor. Aspirin was ordered at 2229. None of these orders were implemented. An order written at 2305 for Phenobarbital administration was not implemented. At 0107, a physician's note referenced the patient had a seizure and fall with a head injury outside the ED waiting room area. Findings revealed the patient had delays with nursing assessments, and failure to implement orders, including medication administration, and following the CIWA protocol. The patient subsequently had a seizure and fall with a resulting head injury.

4. Patient #28 presented to the ED on 07/05/2022, was critically ill, intubated and diagnosed with bacterial meningitis. The patient developed a low blood pressure and a Levophed IV drip was started. Findings revealed the Levophed IV drip was allowed to run dry and the patient's blood pressure dropped to 33/18. A trauma PA was requested by the family for help related to alarms and the patient's condition and the PA indicated the patient was not the PAs assigned patient. The patient arrested. A new Levophed bag was hung. The patient and IV were not monitored and the bag ran dry with subsequent cardiac arrest.

5. Patient #27 arrived in the ED on 07/04/2022 at 0025 with a reported pain level of 10 of 10. The patient had a STAT CT of the abdomen and pelvis ordered at 0027 that was not completed until 0755 (7 hours, 27 minutes later) resulted and signed at 0825. The patient had pain reported as 10 of 10, with nausea and vomiting with vital signs at arrival at 0025 and was medicated with Dilaudid (narcotic pain medication) at 0739 (7 hours and 14 minutes after arrival). The patient was diagnosed with a small bowel obstruction and had surgery that day. The patient had a delay with STAT lab work, STAT CT, nursing reassessment and pain management.

6. Patient #29 arrived on 04/05/2022 at 1451 via EMS and had atrial fibrillation (abnormal heart rhythm) on arrival. The patient had a recent fall with fracture prior to arrival. Pulse Oximetry was 94% prior to arrival. 1630 pulse oximetry was 90% (1 hour and 39 minutes after arrival) with no evidence of oxygen administration at hospital. Dilaudid 0.5 milligrams (mg) IV was administered at 1630 and at 1816. No vital sign or oxygen assessment on an elderly patient was assessed on the patient with a prior pulse oxygen of 90% after the administration of Dilaudid. The patient was subsequently asystole at 1909 and expired. Patient #29 had one set of vital signs from 1451 until time of death at 1909 (5 hours and 18 minutes). Nursing staff failed to reassess the patient after narcotic administration. Nursing staff failed to reassess the patient for a change in condition (not breathing).

7. Patient #6 arrived to Hospital B with strokelike symptoms at 10 days postpartum. She was accepted for transfer to Hospital A as an ED to ED transfer. Patient #6 arrived to the hospital via EMS on 10/03/2023 at 1942. The patient waited in the ED for a bed and continued to be managed by EMS. No documentation was noted by a medical provider until 2223 and Patient #6 was not triaged or assessed by hospital nursing staff until 2227 (approximately 2 hours 45 minutes after arrival by EMS). There was a delay in accepting the patient and a delay in triage, assessment and monitoring by nursing staff.

8. Patient #1 arrived as a transfer on 10/31/2023 at 2314 by EMS. No triage, nursing assessment or evaluation was completed in the ED. The patient was transported to the NSICU (Neurosciences Intensive Care Unit) on 11/01/2023 at 0105. A nursing note was written that stated the nurse was only transporting the patient to the inpatient unit and had not assumed care of the patient. The first nursing vitals or assessment were done at 0110 in NSICU. EMS monitored Patient #1 in the ED and nursing failed to accept, triage and provide care to a patient in the ED.

9. Patient #2 was brought to the ED by EMS from home. The patient arrived on 10/17/2023 at 1753 with chest pain and a syncopal episode at home. The provider ordered labs at 1841 (48 minutes after Patient #2 arrived), and the labs were not collected by nursing staff until 1920 (39 minutes after orders), after the patient was triaged at 1900 (1 hour and 7 minutes after arrival). The patient was on a cardiac monitor and received vital signs by EMS until triage at 1900. No hospital EKG was completed until 1905 (24 minutes after order and 1 hour 12 minutes after arrival). The elevated D-Dimer did not result until 2006, the elevated Pro BNP did not result until 2023 and the elevated Troponin did not result until 2039. At 1953 a physician responded to the patient's bedside due to a cardiac arrest. CPR was started and the patient expired. Nursing staff failed to accept the patient upon arrival to the ED, resulting in delayed triage, care and treatment.

10. Patient #26 presented to the ED via EMS on 09/01/2022 at 1845 for complaints of abdominal pain, decreased appetite, watery non-bloody diarrhea, and right-calf burn. Review of the patient's closed medical record lacked nursing documentation related to the assessment and treatment of the patient's right calf wound from presentation in the ED on 09/01/2022 through discharge on 09/07/2022.

11. Closed medical record review of Patient #12 revealed a 41 year old female transferred to the ED (emergency department) on 07/18/2023 at 1623 via EMS (emergency medical service) for abdominal pain, nausea, chills, and evaluation by general surgery for concerns of appendicitis. Record review revealed the patient did not have her vital signs monitored and had no nurse assigned to monitor status or provide care.

Based on policy review, medical record review, incident report review, Emergency Medical Services (EMS) trip report review, and staff and provider interviews, hospital nursing leadership staff failed to ensure policies were implemented to evaluate, monitor and provide treatment for patients presenting to the emergency department resulting in delays and lack of triage, nursing assessment, monitoring, and implementation of lab, telemetry, medication and treatment orders for eleven (11) of 35 patients records reviewed (Patient #'s 92, 83, 43, 28, 27, 29, 6, 1, 2, 12 and 26).

The findings included:

Review on 12/06/2023 of the hospital policy "Triage - Emergency Department 1PC.ED.0401" revised 07/2023 revealed, "...DEFINITIONS: ... A. Triage Assessment: The dynamic process of sorting, prioritizing, and assessing the patient and is performed by a qualified RN (Registered Nurse) at the time of presentation and before registration. This is a focused assessment based on the patient's chief complaint and consists of information, which is obtained that would enable the Triage RN to determine minimal acuity. A rapid or comprehensive triage assessment is completed, with a goal of 10 minutes, on arrival to the emergency department. 1. A rapid triage assessment is composed of airway, breathing, circulation and disability, general appearance, eliciting symptom driven presenting complaint(s), and any pertinent objective and subjective data/assessment from the patient or parent or caregiver. 2. A comprehensive assessment, performed on each patient that presents to the emergency department, is a focused physical assessment including vital signs, pain scale, allergy, history of current complaint, current medications, exposure to infectious disease, and pertinent past medical/surgical history. ... B. Triage Acuity Level - The Emergency Severity Index (ESI) is a five level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs. C. Reassessment - A process of periodic re-evaluation of the patient's condition and symptoms prior to and during the initiation of treatment. Reassessment components may include some or all of the following: vital signs, a focused physical assessment, pain assessment, general appearance, and/or responses to interventions and treatments. Reassessment after the medical screening exam are performed by RN's (Registered Nurses) according to acuity or change in patient's condition. D. Vital Signs - Helps nursing personnel determine the stability of patients and acuity of those that are that are presenting with life-threatening situations or who are in high-risk categories. Usually refers to temperature, pulse rate, respiratory rate, and blood pressure. May include pulse oximetry for patients presenting with respiratory and/or hemodynamic compromise, and pain scale for those patients with pain as a component to their presenting complaint...PROCEDURE: ...B. All patients presenting for care will be evaluated by an RN. This RN should complete a brief evaluation of the patient, including immediate compromise to a patient's airway, breathing, or circulation.... H. If there is no bed available, the patient will need to wait in the lobby. While in the lobby, patient reassessment and vital signs should be documented in the health record in accordance with documentation guidelines. ..."

Review on 12/09/2023 of the "Assessment and Reassessment" policy revised 06/2021 revealed, "... PURPOSE: A. The goal of the assessment/reassessment is to provide the patient the best care and treatment possible ... The nursing process is utilized in order to achieve this goal. This process includes assessing, analyzing, planning, implementing and evaluating patient care or treatment. ... DEFINITIONS: A. Assessment: The multidisciplinary assessment process for each patient begins at the point where the patient enters a (facility name) facility for care, and in response to changes in the patient's condition. ... The assessment will include systematic collection and review of patient-specific data necessary to determine patient care and treatment needs. B. Reassessment: The reassessment process is ongoing and is also performed when there is a significant change in the patient's condition or diagnosis and in response to care. ... SECTION VI: EMERGENCY DEPARTMENT: A. Patients should be triaged following guidelines set forth in the system Triage Policy (1PC.ED.0401), including documentation of required elements within the electronic medical record (e.g. Vital signs, Glasgow Coma Scale (GCS)). B. The priority of data is determined by the patient's immediate condition. On arrival to unit, an initial assessment is initiated and immediate life-threatening needs are determined with appropriate interventions implemented. C. Patient assessment should be performed based on the developmental, psychosocial, physiological, and age-specific needs of the individual. D. Focused patient history and physical assessment are based on patient's presenting problem(s) including individual indicators of vulnerability. E. Reassessment: 1. Reassessment is ongoing and may be triggered by key decision points and at intervals based on the needs of the patients. Additional assessment/reassessment elements and frequency are based upon patient condition or change in condition, diagnosis, and/or patient history, not to exceed four hours. Interventions may warrant more frequent assessments...."

1. Closed medical record review on 12/09/2023 of Patient #92 revealed a 69 year-old male that presented to the emergency department on 11/09/2023 at 1149 via private vehicle with a chief complaint of chest pain. The patient was triaged at 1155 with a chief complaint of "Woken from sleep at 0400 with midsternal chest pain, described as sharp and pressure. No SOB (shortness of breath), arm/jaw/back pain, or diaphoresis (sweating). H/o (history of) colon CA (cancer) with mets (metastasis) to the lung, currently on chemotherapy...." Review revealed vital signs of blood pressure (BP) 125/60, pulse (P) 57, temperature (T) 97.4 degrees Fahrenheit, oxygen saturation (O2 Sat) 97% and a pain level reported as 2 (scale 1-10 with 10 the worst). Review revealed a triage level of 2 (level 1 most urgent). Review revealed a Medical Screening Examination by a physician was started in the waiting room area at 1209. Review of the physician's notes recorded the patient's chest pain had been waxing and waning, coming in waves and lasting about five minutes at a time. Review revealed a plan to conduct an ED chest pain work-up including a chest x-ray, EKG and labs including CBC, chemistry, lipase and troponin, and administer a dose of aspirin. Review recorded a differential diagnosis of GERD (gastroesophageal reflux disease), referred abdominal pain, musculoskeletal chest pain, ACS (acute coronary syndrome), with lower suspicion for PE (pulmonary embolus) given no tachycardia, hypotension, or evidence of DVT (deep vein thrombosis) on exam. Review revealed the ED physician recommended admission for further chest pain workup based on risk factors. Review of physician's orders revealed labs were ordered at 1218, collected at 1320 and resulted at 1332. Review revealed a troponin result of 0.013 (normal). Review revealed a physician's order placed at 1218 for continuous ECG (telemetry) monitoring in the ED. Review of the ED record revealed no evidence that continuous ECG monitoring was initiated in the ED. A chest x-ray was ordered at 1220 and resulted at 1246 with normal results. An EKG was completed at 1224 which showed sinus rhythm with premature atrial complexes (PACs), with no changes when compared with a prior EKG done in 2022 per the physician's read. A troponin resulted at 1320 as 0.013 (normal) and a baby aspirin was administered as ordered at 1334. A second troponin ordered at 1607 and resulted at 1704 as 0.014 (normal). Review of a second EKG completed at 1628 revealed "Sinus rhythm with premature atrial complexes (PACs). Otherwise normal ECG. When compared with ECG of 09-Nov-2023 12:24, Non-specific change in ST segment in inferior leads. ST elevation now present in Lateral leads." Review recorded the ECG was confirmed by a physician on 11/09/2023 at 1821. Review revealed a physician's order at 1659 for nitroglycerine 0.4 milligrams (mg) sublingual every five minutes times three as needed (prn) chest pain. Record review revealed no nursing assessment/reassessment documented after the patient's triage was recorded at 1155. The patient was administered Morphine (narcotic pain medication) 2 milligrams intravenously (IV) at 1703 by a medic for a pain level of 4. There was no reassessment of the patient's pain and no documentation of the patient's condition by a nurse. The patient was moved from the waiting room to a bed in the orange pod (admission holding area of the ED) at 1937. Nitroglycerine 0.4 milligrams sublingual was administered by a nurse times one for a pain level of 10 at 2013. Review revealed no reassessment of the patient's response to the medication intervention and no nursing assessment of the patient's condition was documented. The patient was transported from the ED to a medical surgical floor on 11/09/2023 at 2054. The patient was placed on continuous telemetry at 2111 when he was noted to be in Atrial Fibrillation with Rapid Ventricular Rate (abnormal heart rhythm). Review of the ECG completed at 2110 recorded an "ST elevation consider lateral injury or acute infarct ** ** ACUTE MI / STEMI (myocardial infarction or heart attack) ** ** ...". Review of a Cardiovascular Consult History and Physical documented on 11/10/2023 at 0020 as an Addendum revealed the patient "... went into AF/RVR (Atrial Fibrillation with Rapid Ventricular Rate) at 2110 hrs this evening with ECG demonstrating evolving high lateral STEMI (l, aVL) which was more pronounced on follow-up ECG at 2210 hrs prompting formal STEMI activation for emergent cardiac catheterization. ..." Review of a Discharge Summary dated 11/13/2023 at 1211 revealed the patient was discharged home on 11/13/2023 with a diagnosis of STEMI (ST elevation myocardial infarction), Coronary Artery Disease, Hypertension, and Atrial Fibrillation with RVR.

Interview on 12/09/2023 at 1210 with Assistant Director of Nursing (ADON) #17 revealed Patient #92 was identified as a level 2 triage and should have been assessed every four hours at a minimum, every two hours for a level two and with any change in the patient's condition. Interview revealed the patient developed chest pain and required interventions and no nursing assessments or reassessments were documented in the ED record. Interview revealed continuous telemetry was ordered for the patient at 1218 and telemetry was not placed on the patient in the ED. Interview revealed the telemetry was placed on the patient at 2111 once the patient transferred to the medical floor.

In summary, Patient #92 presented to the ED with chest pain on 11/09/2023 at 1149. The patient was not assessed by a nurse after triage was completed at 1155, or with a change in condition, or after pain medication was administered at 1703. The patient was transferred to a medical floor and placed on telemetry at 2111 when he was found to be in atrial fibrillation with rapid ventricular rate. Findings of an EKG at 2110 showed ST elevation, **ACUTE MI/STEMI**. A STEMI Code Activation was initiated for an evolving lateral STEMI. The patient underwent an emergency cardiac catheterization at 2249. ED nursing staff failed to provide ongoing assessment of the patient's condition and follow physician's orders for application of continuous telemetry.


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2. Review on 11/17/2023 of the hospital policy Turn Around Time, last revised 11/17/2021 revealed "...PURPOSE: To provide timely and efficient testing services for routine, critical and high-risk situations. DEFINITIONS: Turn Around Time (TAT): the time elapsed from order placement to result reporting. Categorized as: Pre-analytical Phase: the period between test order entry by the caregiver and specimen receipt in the Laboratory. May be influenced, but not controlled by the Laboratory. Analytical Phase: the period between specimen receipt in the Laboratory and result reporting. Controlled by the Laboratory...STAT: an emergent, potentially life-threatening request. NOW: as soon as possible. Synonymous with ASAP. POLICY: All tests will be performed without delay to maximize specimen quality and integrity. STAT, NOW ... requests will be managed as priority situations. First-in, First-out (FIFO) processes are utilized to facilitate rapid and efficient movement of specimens through the system. Requests are also prioritized based on the following criteria to meet defined turn-around times: ...Response to STAT requests: ...STATS take priority over other specimens and should be managed from time of receipt until result reporting with no interruption in handling or testing. In general, the maximum TAT for most tests is 45-50 minutes from order receipt.... Response to NOW/ASAP requests: ...Staff will immediately process the specimen, perform testing, and verify results. Results should be available within (1) one hour from specimen receipt.... TAT Summary (Inpatient): STAT, Time from ORDER Receipt 45-50 minutes. NOW, Time from SPECIMEN receipt 1 hour..."

Closed medical record review on 12/06/2023 revealed Patient #83, a 74-year-old female patient who arrived at the emergency department (ED) via emergency medical services (EMS) on 11/28/2023 at 1216 with a chief complaint of dizziness from her doctor's office. Patient #83 was seen by an ED Medical Doctor (MD) #1 on arrival and at 1218 a comprehensive metabolic panel (CMP) [includes serum glucose] was included in laboratory tests ordered as STAT (an emergent, potentially life-threatening request) with continuous ECG monitoring. At 1259 Patient #83 was placed in Red Pod (for the most acute patients) Hallway Bed-17. At 1309 the first set of vital signs was recorded by RN #2 as temperature 98.7, heart rate 84, respirations 19, blood pressure 225/88, and oxygen saturation of 93 percent on room air. At 1316 Registered Nurse (RN) #3 completed a nursing triage assessment and Patient #83 was given an emergency severity index (ESI) [level 1 as the most urgent and 5 as the least urgent] of 3-urgent. Review of the CMP history revealed the STAT lab was collected at 1358 by RN #3 (1 hour and 40 minutes after the order was placed), the blood specimen arrived at the laboratory at 1412, and resulted at 1532 (3 hours and 14 minutes after the STAT order was placed) with a serum glucose resulted of 1137 (high normal range 120). Review of the Physician's Order on 11/28/2023 at 1626 by ED Nurse Practitioner (NP) #5 revealed a new order for an Insulin (IV medication to reduce serum glucose) IV infusion to be started (54 minutes after the glucose had resulted). At 1709 an Insulin drip was initiated for Patient #83 by the RN #3. At 1739, the Hospitalist NP #6 placed a continuous telemetry monitoring order for 48 hours for Patient #83, with vital signs every 2 hours while in the ED. At 1908 ED MD #14 ordered a Glycosylated Hemoglobin NOW that was collected at 2128 (2 hours after ordered). At 2109 Patient #83 was moved to the ED Holding-Orange Pod-Room-2 awaiting an inpatient bed. At 2329 Hospitalist MD #9 ordered an IV infusion of D51/2 NS with KCL (Dextrose, Normal Saline, and Potassium Chloride Solution). On 11/29/2023 at 0127 MD #9 ordered a Lactic Acid (carries oxygen from your blood to other parts of your body) level to be drawn "NOW" for "nurse collect" for Patient #83. At 0153 MD #9 ordered to suspend the insulin IV. An addendum was made to the History and Physical at approximately 0200 by MD #9 which revealed "...Unfortunately patient has been on insulin drip since 5pm without continuous fluid administration or repeat blood work, it is currently 2 am, Nursing staff was previously contacted requesting these, later on did let provider know there was difficulty obtaining blood work as well as delay in obtaining D51/2NS KCL fluid from pharmacy. Given we have no blood work, no fluids, for the safety of the patient will suspend insulin drip at this time, until blood work is back to ensure appropriateness of insulin drip infusion..." 0157 RN #10 documented the IV with D51/2NS KCL as started (2 hours and 27 minutes after ordered). At 0200 Patient #83's Insulin IV was suspended by RN #10. At 0256 Patient #83's Insulin IV was reordered and was resumed (56 minutes after it was stopped). On 11/29/2023 at 0514 Patient #83 was transported to a Stepdown Unit. Review of the ED record revealed no evidence that continuous telemetry monitoring or vital signs every 2 hours were initiated in the ED by a nurse, further the NOW Lactic Acid "nurse collect" order at 0127 was never drawn while the patient was in the ED. On the inpatient floor, at 0529, RN #11 canceled the 0127 NOW Lactic Acid order "nurse collect" from the ED and reordered the NOW Lactic Acid order "lab collect". The Glycosylated Hemoglobin NOW that was ordered 11/28/2023 at 1908 resulted on 11/29/2023 at 0743 (12 hours and 35 minutes after ordered) with result of 12.3 (normal high range 6.3). At 0844 the Lactic Acid was drawn (3 hours and 15 minutes after it was ordered), was in the lab for processing at 0907, and resulted at 1108 (5 hours and 39 minutes after ordered) as "7.48" (high normal for lactic acid was 2.1). The computer system automatically reordered an additional Lactic Acid order by default and was collected at 1119 and was in the lab to be processed at 1148. At 1146 RN #12 documented a blood pressure of 141/67 with respirations of 36. At 1158 Rapid Response was called for Patient #83. At 1206 blood pressure was 65/40. At 1213 blood pressure was recorded at 68/40. At 1225 a Levophed (medication used to increase blood pressure) IV infusion was initiated via interosseous to increase her blood pressure. At 1245 the blood pressure was 126/84 at 98 percent oxygen saturation while the patient was being mechanically bagged at the bedside. At 1247 Patient #83 was intubated (mechanical ventilation), at 1250 Patient #83 was transferred to the medical intensive care unit. At 1256 the second Lactic Acid resulted as critically high "11.96". After discussion with the family, Hospitalist MD #16 changed Patient #83 Full Resuscitation status to Limited Resuscitation with no cardiopulmonary resuscitation (CPR). Patient #83 expired on 11/30/2023 at 1337.

Review on 12/06/2023 of a Patient Safety Analysis (Incident Report) completed by RN #12 on 12/01/2023 at 1917 revealed this Care Event was a "Delay in Care" and the issue was "Lack of timely response to Order", for Patient #83. A description "A NOW LA (lactic acid) order was placed at 0529. Lab wasn't drawn until 0844, and in lab at 0907. Critical results of lactic acid 7.48 reported at 1108. MD at 1114...Shortly after this (within the hour), the patient took a turn and had to be intubated at bedside and sent to ICU (intensive care unit) ...Solution to Prevent this from Recurring? Promptly follow orders..." This Patient Safety Report was still in process. Review of the report revealed Patient #83 had a delay in lab work.

MD #9 was unavailable for interview.

MD #16 was unavailable for interview.

Telephone interview on 12/07/2023 at 1632 with RN #10 who cared for Patient #83 in the Orange Pod (location in the ED for pending admissions) revealed "...I work on an inpatient unit and was pulled to the ED that day. It's a revolving door, I don't recall this patient in particular. If I can't get the labs, I would call a phlebotomist after 3 tries to get the labs if I couldn't..." Interview revealed she could not remember why the NOW lactic acid order was not collected. Interview revealed physician orders for Patient #83 were not followed.

Interview on 12/08/2023 at 0915 with RN #11 revealed she did remember Patient #83 and worked night shift. "...I did not receive a report on this patient from the ED. You have to look up the medical record number and sometimes the charge nurse gets an alert that the patient is coming and will print the face sheet. I had to piece it together and go through the orders. I reordered the lab work when I saw it was pending. My concern is we have had trouble getting in contact with the phlebotomist. That morning they were not logged into to their imobile device. I called the general lab number, and no one answered. I then contacted my house supervisor, and he told me 'we don't have another option right now.' I can't recall if she was on a telemetry box or not, I was only with her over an hour..." Interview revealed not being able to reach a phlebotomist during night shift had happened before. Interview revealed RN #11 had called multiple times to reach the lab phlebotomist to draw NOW blood orders without reaching someone. Interview revealed lab Turn Around Time for NOW lab orders was not followed for Patient #83.

Interview on 12/08/2023 at 1309 with Laboratory Phlebotomist Supervisor #17 revealed "...the phlebotomists do not collect in the ED; we will help if called. All labs ordered in the ED default to "nurse collect". The expectation was for STAT and NOW orders to be from order to collection in 15 minutes and to be resulted in an hour from order..." Interview revealed lab collection for STAT and NOW orders for Patient #83 did not follow hospital policy for lab turnaround times.

Interview on 12/08/2023 at 1414 with NP #6 revealed her expectation for Patient #83, was for her to have continuous ECG monitoring and vital signs every 2 hours while in the ED. Interview revealed physician orders were not followed for Patient #83.

Interview on 12/08/2023 at 1425 with RN #3 who cared for Patient #83 in the Hallway Bed 17 on 11/28/2023 revealed "...I remember her. It was an extremely busy day...she was a hard stick; I used an ultrasound to start her IV. The problem with hallway beds is they have no dedicated monitor. She had a monitor and vital signs ordered. I strongly advocated for her to get moved into a bed with the CNC (clinical nurse coordinator), and it didn't happen. She didn't think it was a big deal. We don't have the capability to link the patient to a monitor in a hallway bed. She wasn't on a monitor; I spent the afternoon telling the CNC and MD. The doctors don't have any say, it's up to the CNC where patients are roomed. I sat behind her all day, ...I was extremely frustrated..." Interview revealed Patient #83 was not placed on continuous ECG monitoring, nor were vital signs monitored every 2 hours. Interview revealed physician orders were not followed for Patient #83.

Interview on 12/08/2023 at 1230 with Nursing VP of ED Services, RN #20 revealed she could not explain the lack of telemetry monitoring or vital signs for Patient #83 while in the ED. Interview revealed the ED nurse should elevate to the ED Charge Nurse for the need to continuously monitor a patient in a hallway bed if one was not available. Further interview revealed the ED Provider and ED Nurse were responsible for monitoring lab results via electronic medical record in the ED. Interview revealed hospital policy was not followed for Patient #83.

Interview on 12/09/2023 at 1159 with Lab Director #18 revealed "...I do know we had a call out that day. The lactic acid was available for the lab tech to see at 1016 but wasn't called to the floor until 1108. I don't know what the delay was. The expectation was to call as soon as the result was available. The expectation for lab collection and processing was to follow the policy guidelines, and for STAT and NOW results to be completed within an hour..." Interview revealed lab collection and processing did not follow hospital policy for Patient #83.

Patient #83 was presented to the ED with dizziness on 11/28/2023 at 1216. The patient had STAT lab work ordered at 1218 with continuous ECG monitoring. Labs were drawn at 1358 (1 hour and 40 minutes after ordered). Labs arrived at the lab at 1412 and resulted at 1532 (3 hours and 14 minutes after ordered). The blood glucose was 1137 (critically high). Insulin IV infusion was ordered at 1626 and initiated at 1709 (1 hour and 13 minutes after ordered and 1 hour and 37 minutes after the glucose resulted). Orders for continuous ECG monitoring placed at 1218, and vital signs every 2 hours were never initiated in the ED. At 2349 an IV infusion of D51/2 KCL was ordered that was not completed until 0157 (2 hours. and 8 minutes after ordered). Lactic acid was ordered NOW at 0127 for nurse collect in the ED. At 0200 a physician wrote there was a delay in labs and fluids so stopped the insulin IV infusion. The lactic acid was not collected in the ED. At 0529 the original lactic acid NOW, order was canceled and reordered as lab collect NOW on the floor. It was collected at 0844 (3 hours and 15 minutes after ordered at 0529) and resulted at 1108 (9 hours and 41 minutes after originally ordered at 0127) with a result of 7.48 critical high. A second lactic acid was reordered at 1108 and resulted at 1256 (1 hr. and 36 minutes after ordered) with a result of 11.96 critically high. A rapid response was called previously at 1158, the patient was intubated at 1247, and ultimately expired on 11/30/2023.

3. Review of the CIWA (Clinical Institute Withdrawal Assessment for Alcohol) /Alcohol Withdrawal Plan, effective date 07/20/2022 revealed "...Monitoring Phase ...Now ONCE, when plan is initiated with goal CIWA < (less than) 15..." The CIWA/Alcohol Withdrawal Plan Reference Information included 10 questions, questions 1-9 can score between 0 and 7 points each question, question 10, can score 0 to 4 points, depending on severity of symptoms for each question. Score range 0-68. Questions with observations: 1. Nausea/Vomiting? 2. Paroxysmal sweats? 3. Agitation? Headache, fullness in head? 5. Anxiety? 6. Tremor? 7. Visual disturbances? 8. Tactile disturbances? 9. Auditory disturbances? 10. Orientation and clouding of sensorium -Ask what day it is? "...CIWA Management Communication If CIWA > 15 for four consecutive hours, contact provider to initiate Severe Withdrawal Phase and/or to consider transfer to higher level of care..."

Closed medical record review on 11/16/2023 revealed Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of "...chest pain, nausea, clammy, lightheaded, and right-side tingling for several week. Drinks 12 beers a day...." At 1603 triage by Registered Nurse (RN) #21 with vital signs: temperature 98.5, heart rate 97, respirations 18, blood pressure 141/89, oxygen saturation of 96 percent on room air, and pain of 4/10 (1 being least pain, and 10 being most pain) and was assigned an emergency severity index [ESI] (level 1 as the most urgent and 5 as the least urgent) of 2. Patient #43 was then moved to the ED waiting room IPA (Internal Processing Area) area and was seen by Nurse Practitioner (NP) #22. At 1650 initial labs, EKG, and chest X-ray were completed, and Patient #43 was assigned to ED Medical Doctor (MD) #23. Review of the ER Physician Note from 08/14/2023 at 1727 by MD #23 revealed a review of lab, EKG and chest X-ray results from 08/14/2023 did not show any critical results. At 1732 MD #23 ordered a GI cocktail (oral combination of medications given for indigestion), Zofran 4 mg orally (medication given for nausea and vomiting). An addendum to MD #23's ER Report Note revealed "...On reassessment patient and his mom who is now accompanying him are updated on his results. He is still in the waiting room unfortunately. I have ordered IV (intravenous) fluids, CIWA protocol and 1 mg of Ativan (a sedative given for anxiety and seizures) as he is slightly tremulous (shaking) and diaphoretic (sweating) my reassessment [sic]...Hospitalist has been consulted for admission..." At 1841 MD #23 placed orders for IV (intravenous) fluids-NS NOW, thiamine (dietary supplement/nutrient) 100 milligrams (mg) orally STAT (immediately), and CIWA scale/protocol (alcohol withdrawal plan/protocol). At 1851 vital signs were rechecked by IPA ED RN #24 temperature 98.3, heart rate of 103, blood pressure 132/82, and oxygen saturation of 92 percent on room air, the GI Cocktail, and Zofran were administered in the ED waiting room. At 1947 MD #23 ordered Ativan 1 mg IV push NOW (urgent). Per the CIWA plan at 2100 a multivitamin orally was ordered and CIWA Scale assessment. The History and Physical was initiated on 08/14/2023 at 2229 by Hospitalist MD #25 while in the ED waiting room, and new orders were placed for aspirin orally NOW, Lopressor (medication given in treatment of alcohol withdrawal) 12.5 mg orally, and again IV access at 2226. At 2305 MD #25 ordered Patient #43 phenobarbital (medication given to prevent seizure) 60 mg orally three times a day STAT and a CIWA Scale reassessment was due to be completed per protocol. No nursing reassessments, medication administrations, IV access/fluids, or physician orders were completed after 1851 for Patient #43 while in the ED waiting room. On 08/15/2023 at 0057 Patient #43 was moved to the Red Pod (ED area for the most acute patients) room 11. At 0105 MD #25 ordered Patient #43 to have Ativan 4 mg IV STAT and was given at 0106 by RN #27. Review of the ER Report Note on 08/15/2023 at 0107 by MD #26 revealed "...I became involved in the patient's care after he apparently left the waiting room where he was awaiting admission and then had a seizure and struck his head on the sidewalk outside of the ER (emergency room) entrance. On my evaluation, the patient seems postictal (the period following a seizure, disorienting symptoms, confusion, and drowsiness), he is not actively seizing. He does have a history of heavy alcohol use, drinks about 12 beers a daily. He has been in the emergency department waiting room for 9 hours and has not received any Ativan or Phenobarbital. I suspect that he seized due to alcohol withdrawal. Will obtain head CT (cat scan) given the patient did strike his head, he also has a small laceration that will require repair...." Record review revealed the ED waiting room orders for IV fluids NOW on 08/14/2023 at 1841 to 08/15/2023 at 0106 (5 hrs. and 25 min), Ativan IV NOW ordered on 08/14/2023 at 1947 to administered on 08/15/2023 at 0106 (5 hours 19 min), and Phenobarbital STAT ordered on 08/14/2023 at 2305 to administered on 08/15/2023 at 0150 (2 hours and 45 min) for Patient #43 were delayed and no CIWA score/assessment was completed until 08/15/2023 at 0437 (9 hours and 56 minutes after ordered). No CIWA score/assessment was documented before the patient had a seizure event with sustained head injury. There was no nursing reassessment, or nursing care after 08/14/2023 at 1851 by RN #22 until 08/15/2023 at 0057 (6 hours and 1 minute). Patient #43 was admitted to an inpatient room on 08/15/2023 at 0334 from the ED. Patient #43 was discharged home on 08/17/2023.

Review of the Patient Care Analysis (Incident) report submitted by MD #25 on 08/15/2023 at 0443 revealed the date of event was 08/15/2023 at 0000. Brief description revealed "...patient was in waiting room for 9 hours, did not receive any medications for alcohol withdrawal, then had a seizure and sustained a head injury..." Investigator #28 Notes revealed: We continue to work through ways to provide care to patients in the waiting room during peak times of surge and limited staffing..." Further comments were reviewed by the hospital Pharmacy, dated 11/17/2023 (3 months after the event) that revealed "...Suggest education to sent out of CIWA precautions...Nurse could have clarified with provider about the CIWA order and administered medication..." Level of Harm was documented as "Harm-required intervention" and Primary Action to Prevent Recurrence: "Increase in Staffing/Decrease in Workload."

MD #23 declined to be interviewed.

Interview on 11/15/2023 at 1414 with MD #26 revealed "...With the current process it's still difficult to treat patients in the ED waiting room. The goal was for delays in care to not happen, but especially at night it occurs. I have concerns with delays in patient care. The patient was better off in a more clinical area where they can be monitored ..." Interview revealed MD #26 had concerns for patient safety in the ED waiting room due to delays in patient monitoring.

Interview on 11/15/2023 at 1615 with Nurse Practioner (NP) #36 revealed "...it does happen occas

Based on policy review, medical record review, incident report review, EMS trip report review, and staff and provider interviews, hospital nursing staff failed to administer medications and biologicals according to provider orders and standards of practice by failing to administer medications as ordered, and evaluate and monitor the effects of the medication for 6 of 35 patients presenting to the emergency department (#92, #83, #43, #28, #27, and #26).

The findings included:

Cross refer to A-0398 for all examples.

Review of a "Pain Assessment and Management" policy revised 01/05/2022 revealed, " ... Each patient is screened for the presence of pain in all settings where treatment is provided. ... 3. For emergency departments (ED), patients will be screened for pain during each ED visit. ... The frequency of pain assessment is based on patient symptoms, interventions, and progress towards goals. ... Interventions are provided based on the patient's treatment plan for pain. ... The pain management/treatment plan is evaluated on an ongoing basis and is revised to facilitate achievement of pain goals based on best practices, patient's clinical condition, past medical history, and pain goals. ... Pain rating must be documented prior to the administration of PRN pain medication. If opioids are administered, sedation level must also be documented. Pain rating and sedation levels are reassessed within 1 hour after PRN pain administration by any route. If opioids are administered, sedation is evaluated to assess for opioid-induced respiratory depression using one of the following sedation scales: 1. For the non-ICU, non-intubated patient (adult and pediatric), the Pasero Opioid-Induced Sedation Scale (POSS) should be used. ... The pain/treatment plan is evaluated on an ongoing basis and is revised to facilitate achievement of pain goals. ..."

Review of a "Medication Administration" policy revised 03/20/2023 revealed, " ... Pain medications may be administered to treat or prevent pain. Proactive pain management is preferred to reactive. ...For opioid medications ordered "as needed for pain" the level of pain for administration must be specified in the order. 1. If the patient's symptom is unrelieved, the nurse may administer additional doses of PRN (as needed) medications ordered, not to exceed the maximum dose within the prescribed frequency. 2. Subsequent doses are based on the nurse's assessment, the patient's response to the previous dose, absence of adverse effects, and symptom severity. ... Monitor the patient's response. ..."

1. Closed medical record review on 12/09/2023 of Patient #92 revealed a 69 year-old male that presented to the emergency department on 11/09/2023 at 1149 with a chief complaint of chest pain. The patient was triaged at 1155 with a chief complaint of "Woken from sleep at 0400 with midsternal chest pain, described as sharp and pressure. No SOB (shortness of breath), arm/jaw/back pain, or diaphoresis (sweating). H/o (history of) colon CA (cancer) with mets (metastasis) to the lung, currently on chemotherapy...." Review revealed a pain level reported as 2 (scale 1-10 with 10 the worst). Review of the physician's notes recorded the patient's chest pain had been waxing and waning, coming in waves and lasting about five minutes at a time. Review revealed a plan to administer a dose of aspirin. A baby aspirin was administered as ordered at 1334. Review revealed a physician's order at 1659 for nitroglycerine 0.4 milligrams (mg) sublingual every five minutes times three as needed (prn) chest pain. Record review revealed no nursing assessment/reassessment documented after the patient's triage was recorded at 1155. The patient was administered Morphine (narcotic pain medication) 2 milligrams intravenously (IV) at 1703 by a medic for a pain level of 4. There was no reassessment of the patient's pain. Nitroglycerine 0.4 milligrams sublingual was administered by a nurse times one for a pain level of 10 at 2013. Review revealed no reassessment of the patient's response to the medication intervention and no nursing assessment of the patient's condition was documented.

Interview on 12/09/2023 at 1210 with Assistant Director of Nursing (ADON) #17 revealed no nursing assessments or reassessments were documented in the ED record.


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2. Closed medical record review on 12/06/2023 revealed Patient #83, a 74-year-old female patient who arrived at the emergency department (ED) via emergency medical services (EMS) on 11/28/2023 at 1216 with a chief complaint of dizziness. Review revealed a serum glucose resulted of 1137 (high normal range 120). Review of the Physician's Order on 11/28/2023 at 1626 by ED Nurse Practitioner (NP) #5 revealed a new order for an Insulin (IV medication to reduce serum glucose) IV infusion to be started (54 minutes after the glucose had resulted). At 1709 an Insulin drip was initiated for Patient #83 by the Registered Nurse (RN) #3 (1 hour and 13 minutes after ordered and 1 hour and 37 minutes after the glucose resulted). At 2329 Hospitalist Medical Doctor (MD) #9 ordered an IV infusion of D5 1/2 NS with KCL (Dextrose, Normal Saline, and Potassium Chloride Solution). At 0157 RN #10 documented the IV with D5 1/2 NS KCL as started (2 hours and 27 minutes after ordered).

Interview on 12/08/2023 at 1425 with RN #3 who cared for Patient #83 on 11/28/2023 revealed physician orders were not followed for Patient #83.

Interview on 12/08/2023 at 1230 with Nursing Vice President (VP) of ED Services, VPED #20 revealed hospital policy was not followed for Patient #83.

3. Closed medical record review on 11/16/2023 revealed Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of "...chest pain, nausea, clammy, lightheaded, and right-side tingling for several week. Drinks 12 beers a day...." Patient #43 was assigned to ED Medical Doctor (MD) #23. At 1732 MD #23 ordered a GI cocktail (oral combination of medications given for indigestion), Zofran 4 mg orally (medication given for nausea and vomiting). An addendum to MD #23's ER Report Note revealed "...I have ordered IV (intravenous) fluids...1 mg of Ativan (a sedative given for anxiety and seizures) as he is slightly tremulous (shaking) and diaphoretic (sweating)...Hospitalist has been consulted for admission..." At 1841 MD #23 placed orders for IV (intravenous) fluids-NS NOW, and thiamine (dietary supplement/nutrient) 100 milligrams (mg) orally STAT (immediately). At 1851 the GI Cocktail and Zofran were administered. At 1947 MD #23 ordered Ativan 1 mg IV push NOW (urgent). At 2100 a multivitamin orally was ordered. The History and Physical was initiated on 08/14/2023 at 2229 by Hospitalist MD #25 while in the ED waiting room, and new orders were placed for aspirin orally NOW, Lopressor (medication given in treatment of alcohol withdrawal) 12.5 mg orally, and again IV access at 2226. At 2305 MD #25 ordered Patient #43 phenobarbital (medication given to prevent seizure) 60 mg orally three times a day STAT. No medication administrations, IV access/fluids, or physician orders were completed after 1851 (when the GI Cocktail and Zofran was administered) for Patient #43 while in the ED waiting room. At 0105 MD #25 ordered Patient #43 to have Ativan 4 mg IV STAT and was given at 0106 by RN #27. Review of the ER Report Note on 08/15/2023 at 0107 by MD #26 revealed "...I became involved in the patient's care after he apparently left the waiting room where he was awaiting admission and then had a seizure and struck his head on the sidewalk outside of the ER (emergency room) entrance. On my evaluation, the patient seems postictal (the period following a seizure, disorienting symptoms, confusion, and drowsiness), he is not actively seizing. He does have a history of heavy alcohol use, drinks about 12 beers a daily. He has been in the emergency department waiting room for 9 hours and has not received any Ativan or Phenobarbital. I suspect that he seized due to alcohol withdrawal. Will obtain head CT (cat scan) given the patient did strike his head, he also has a small laceration that will require repair...." Record review revealed the ED waiting room orders for IV fluids NOW on 08/14/2023 at 1841, Ativan IV NOW ordered on 08/14/2023 at 1947, and Phenobarbital STAT ordered on 08/14/2023 at 2305 for Patient #43 were delayed.

Interview on 11/15/2023 at 1615 with NP #36 revealed "...it does happen occasionally that orders in the ED waiting room are on hold until the patient can be roomed. I do have concerns about it..." Interview revealed NP #36 had concerns provider orders were not completed timely in the ED waiting room.

Interview on 11/16/2023 with ED Internal Processing Area (IPA) Day RN #22 revealed she did not remember Patient #43. Interview revealed "...best practice was to go back to see if patients' meds (medication) were helpful. I must have left before I was able to put in a reassessment..." Interview revealed RN #22 cared for Patient #43 until 1900 and did not remember doing a reassessment after medication administration.

Interview on 11/28/2023 at 1639 with ED IPA Night RN #28 revealed she did not remember Patient #43. Interview revealed "NOW orders in the IPA area go by priority and ESI (Emergency Severity Index ESI - score to determine patients with most to least urgent needs), we are not always able to do them. The CNC (Clinical Nurse Coordinator should be informed...If you are the only IPA nurse and the doctor says 'this has to happen now' then it's the next on my list. There was no protocol for who was actually assigned patients in the waiting room. Reassessments for ED patients who are waiting in the lobby would fall under the IPA nurse tasks but they are doing other patient's needs and medications as well. There were only two ways to know if additional orders are placed on a patient after IPA, the doctor tells you, or on the tracking board, you might see "repeat troponin", the CNC was supposed to help with that. If I gave controlled medication in the waiting room, I am responsible for the reassessment. If we are caught up it is a part of our duties to reassess..." Interview revealed patients in the ED waiting room are not assigned a nurse for reassessment and monitoring. Interview revealed hospital policy for reassessment in the ED was not followed for Patient #43.

Interview on 12/08/2023 at 1230 with Nursing VP of ED Services, VPED #20 revealed she could not explain the lack of completion of provider orders in the ED waiting room. Interview revealed any new outstanding provider orders for patients in the ED waiting room would be elevated to the CNC. Further there was a WebEx huddle (meeting virtually for many hospital departments to discuss and prioritize patient needs) held every 2 hours and any outstanding provider orders would be delegated to be completed. Interview revealed RN #20 could not explain why Patient #43's providers orders had not been completed.

4. Closed medical record review on 11/14/2023 revealed Patient #28, a 48-year-old male patient who arrived at the emergency department (ED) by emergency medical services (EMS) on 07/05/2022 at 0947 with headache x 2 weeks, altered mental status, fall, and was combative. At 1050 Patient #28 was intubated (mechanical ventilation) with standard IV sedation protocols. At 1236-1311 Patient #28 went into ventricular tachycardia (lethal heart rhythm) and was coded (resuscitated by staff), defibrillated, and had a central line placed. Review of the ER Report Reexamination/Reevaluation (not timed) by MD #59 revealed "...the patient ultimately did require intubation for sedation and airway protection, his mental status continued to worsen despite Haldol and Versed...The Head CT was negative...Once back from CT the patient became profoundly hypotensive and at 1 point lost pulses requiring CPR, total time roughly 5 to 10 minutes...We have been running norepinephrine (given to sustain blood pressure) through this...ICU (intensive care unit) has been consulted...." At 1409 Pulmonologist/ICU MD #60 ordered Levophed (used to treat life-threatening low blood pressure) 4 mg in 250 milliliters (ml) to titrate to 30 micrograms (mcg)/per minute and was initiated by RN #56 at 1514 (1 hour and 5 minutes after ordered), and at 1655 this drip rate was adjusted to 20 mcg/min. At 1740 blood pressure was 137/79, at 1750 blood pressure was 73/42, at 1800 blood pressure was 33/18. Review of the Medication Administration Record revealed at 1801 RN #68 initiated a bag of Levophed at 30 mcg/min for Patient #28. At 1803 a code was initiated, and Patient #28 was in asystole (no heart rhythm). The code ended at 1807 with the return of blood pressure. At 1814 blood pressure was 249/118 with a pulse of 145. At 1816 an addendum to the ER Report by MD #62 revealed "...At 1803 I was called to the patient's room, who had gone asystole. I was notified of the patient's diagnosis of meningitis and hypotension. CPR was in progress on my arrival...I was notified that the patient's Levophed had run dry, and that the patient had been hypotensive (low blood pressure) sometime before coding...Shortly after the epi (epinephrine-used to return pulse) and bicarb (bicarbonate improves outcomes in cardiac arrest), (1807) we had return of pulses. Patient's blood pressure high. ICU attending entered shortly after the code finished." At 1940 Patient #28 was transferred to the medical ICU for admission. Patient #28 continued to decline and showed no signs of improvement. Review of the Discharge Summary date 07/15/2022 at 1525 by Doctor of Osteopathic Medicine, DO #63 revealed "...There was no change in neurology exam, and it was explained to the family that there were no signs of meaningful improvement. At this time the family changed its code status to DNR (do not resuscitate)...at this time the family was amenable...for organ procurement. He was brought to the OR (operating room) this morning where he was extubated (removal of mechanical ventilation), and time of death was 1040..."

Review on 11/28/2023 of the Patient Safety (Incident) Report for Patient #28 revealed it was reported by: (named RN #57) on 07/05/2022 at 1930. Event #: 6858. Event time was 07/05/2022 at 1803 with brief description "...assigned 5 patients, pt. (patient) coded due to unsafe staffing ratio...additional comments ...NUS (nursing unit supervisor RN #74) and Director (named, RN #75) notified of unsafe assignment at approx. 1730. RN (named RN #56) responded to assigned Trauma Alert which arrived at 1748. Pt. coded at 1803, 1 round of CPR, epi, sodium bicarb, ROSC (return of spontaneous circulation). Pt's levophed emptied due to unsafe staffing assingment [sic]which was reported to NUS and Director prior to event..." Review on 07/06/2022 by Investigator and Director of ED Services (named RN #76) revealed one of the ED managers had spoken to Patient #28's family member. The family was upset because they had "...asked for help at the doorway of the patient's room when she noted alarms going off in the room. A PA (Physician's Assistant PA #77) was at the nurse's station from a different service line that reportedly did not respond to her request..." Further the CNC, RN #74 reported she was only notified RN #56 needed assistance when the patient was coding. Patient #28 did code 2 times during his ER stay and had a length of stay of 9:52 (9 hours and 52 minutes) in the ER. RN #56's patient assignment was broken down by RN #76 in the report as two stable patients awaiting admission to step down units (2), one patient who had been moved to the hallway (1), a new Trauma Alert patient (1), and Patient #28, an ICU patient (1). (RN #56 was assigned and responsible for 5 patients during Patient #28's code/event). RN #76 discussed collateral staff available in the ED to support RN #56. "...Background information: The House was unable to provide staffing support for the admit holds in the ER on this date. There was an ER census of 295 on this date..." On 07/07/2022, Vice President (VP) of ED Services, VPED #48 reviewed this Patient Safety Report. Her investigation revealed there was an additional Patient Safety Report for this same event "...Indicating that the ER Director was informed of an alleged unsafe patient assignment. This notification to the Director was not substantiated..." Additionally, VPED #48 agreed RN #56's assignment was safe due to collateral staffing in the ED. And did mention Patient #28's family had voiced concerns who did not respond to their request for help for alarms in the room with (named, PA #77). The Primary Contributing Factor was "Human Factors/Staff Factors...Competing priorities...Level of Harm Harm-intervention to sustain life..." In summary, Patient #28's levophed IV infusion sustaining his blood pressure was allowed to run dry, his blood pressure dropped, he was coded for 7 minutes until the infusion was reinstated. RN #56 had a patient assignment of 5 patients.

Review on 11/28/2023 of the Patient Safety Analysis report, Event #6856, referencing Patient #28 dated 07/05/2022 at 1843 by ED Clinical Pharmacist, ED RPH #78 revealed the event date was 07/05/2022 at 1800 with a brief description of "...Patient required CPR (cardio-pulmonary resuscitation) due to levophed running dry while RN was attending to other patients (RN had 5 pts), including two traumas and this ICU patient...additional comments...making this report on behalf of (named RN #56) as he does not have time to make report. (Named) had 5 patients: the patient from this report (named) intubated, ICU, a trauma alert, a trauma transfer-a comfort care patient in the hall, and two other admitted patients. While he was in one of the traumas, this patient's norepinephrine infusion ran dry-the patient became hypotensive. The family of the patient was monitoring the BP (blood pressure) and tried to get help from a non-ER provider who was sitting at a computer outside the room and this provider told the family that he could not help them because it was not his patient. Family is irate about this. A few minutes later, another RN came into the room and was able to switch out the levophed, but by this point the pt's SBP (systolic blood pressure) was in the 30's. He then became aystolic and required a round of CPR. (Named RN #56) alerted the ER NUS throughout the day that his assignment was unsafe. This patient coding was a direct result of an unsafe and unreasonable assignment..." This Report was investigated by ED Director, RN #76 on 07/06/2022 without any new findings from previous Event #6858. Additionally, on 07/21/2022 Doctor of Pharmacy, PharmD #79 added investigator notes to this report. The leading description of harm cited by PharmD #79 was "Human Factors/Staff Factors...Level of Harm...Harm-intervention to sustain life..." A summary of her report revealed that a bag of levophed was pulled for Patient #28 on 07/05/2022 at 1511 by RN #56 and was documented on the Medication Administration Record as given on 07/05/2022 at 1514, and per her estimation of the rates of infusion, the bag of levophed "...would have likely run out 1745..." The next bag of levophed was pulled on 07/05/2022 at 1757 by ED RN #68 and was started at 1801 for Patient #28. Review revealed Patient #28's levophed IV infusion was interrupted for 16 minutes; he was coded from 1803 to 1810 before returning to spontaneous circulation.

Request to interview ED RN #68 revealed she was not available for interview.

Request to interview ED RPH #78 revealed she was unavailable for interview.

Request to interview ED Manager RN #75 revealed he was unavailable for interview.

Request to interview ED Director, RN #76 revealed she was unavailable for interview.

Interview on 11/15/2023 at 1014 with RN #56 revealed he remembered Patient #28 and had worked in the ED for 5 years. Interview revealed "...I had trauma bay 11, and rooms 10, 9, 8 initially. The patient in room 10 was combative, intubated and a danger to himself and was receiving the maximum dose of levophed to keep his blood pressure elevated. I had him around 10 hours of my day. I got a trauma patient, and they were going to assign me another new trauma patient. Around 1730 I went to CNC (named RN #74) to discuss my assignment and the acuity of my already 4 patients, she put my dying trauma patient in the hallway, to make room for the new trauma patient even when I explained I felt my assignment was unsafe. I had already approached her that morning after 0800 to explain the acuity of my patients. So, then I went to my Nurse Manager (named, RN #75) to discuss my assignment and was assigned the new trauma anyway. My new trauma patient had just arrived after 1730, I was working with them and didn't realize a code had been called for my intubated patient. When I arrived in the room (named RN #68), the person who was assisting me while I was caring for the new trauma patient, had already hung a new bag of levophed, and the code was in progress. I was very upset. I voiced my concerns, I talked to the administration, to the ethics and compliance committee and filed a complaint with HR (human resources). I tried to document this the best I could..." Interview revealed RN #56 had gone to the CNC, RN #74 at 0800 and again before new assigned trauma patient to voice his concerns with his high patient acuity assignment. Interview revealed RN #56 was caring for another patient, when the levophed IV infusion ran out, causing Patient #28's blood pressure to drop, and a code was initiated. (request for all documents filed by RN #56 administration, ethics committee and HR were not made available for this surveyor).

Interview on 11/15/2023 at 1637 with VPED #20 revealed hospital policy for Patient #28 was not followed.

Telephone interview on 12/01/2023 at 1209 with Director of the Trauma Team, MD #80 revealed he was aware of the case with Patient #28 and was the Medical Supervisor for PA #77 in 2022 and currently. Interview revealed "...when a Trauma Team member was in the ED it was to care for a specific consulted trauma patient, however a Trauma Team member if clearly evident could assist any patient in a life sustaining emergency..." The interview revealed PA #77 would not be allowed to touch an IV drip or alarming IV pump of a patient they were not consulted on. Interview revealed PA #77 notified a person who could adjust the drip for Patient #28. Further interview revealed he had no concerns with PA #77's patient care, and the Trauma Team Supervisor, RN #81 had communicated with PA #77 "...we should always respond with compassion to family..." regarding this event. Interview revealed MD #80 had not followed up with PA #77, the Trauma Team Director had talked with PA #77. Interview revealed PA #77 did not know Patient #28's blood pressure was low or the levophed had run out but had communicated to ED nursing staff who could attend the alarms when family asked him.

Telephone interview on 12/01/2023 at 1241 with Trauma Team PA #77 revealed he had been employed for 8 years. Interview revealed "...I am only in the ED when called/consulted for a specific trauma patient. The family came to the desk, I told them I can get your nurse, and I did. The family was asking about an IV beeping. If I thought he was coding, I would have made sure he was OK. I did not have that information. I only learned about the IV levophed today. Of course, I would respond to help a patient coding. I would not 'shirk' a patient needing help..." Interview revealed PA #77 recalled the family asking for help with an IV alarm. He told the family he would find the nurse, and he did.

5. Closed medical record review on 11/14/2023 revealed Patient #27, a 66-year-old female who arrived at the emergency department (ED) on 07/04/2022 at 0025 by private vehicle with abdominal pain, nausea, and vomiting. Patient #27 was triaged at 0025 by RN #38 with a pain score of 10 (1 least pain and 10 being the most pain). At 0028 Nurse Practitioner (NP) #39 wrote orders for an IV (intravenous) of Normal Saline to be started and Ondansetron (medication for nausea) 4 milligrams (mg) IV to be given. Record review did not reveal physician orders for IV and medications were implemented for Patient #27 while in the ED waiting room (6 hours and 3 min). Patient #27 was seen by MD #26 at 0656 and orders were placed for ondansetron 4 mg, and Dilaudid (narcotic pain medication) 0.5 mg for pain. At 0739 Patient #27 had an IV started of NS (7 hours and 11 minutes after ordered), and medications for pain (7 hours and 14 minutes after identified pain level of 10, and 43 minutes after pain medication ordered) and nausea (7 hours and 11 minutes after original order) were administered by RN #40. At 0742 vital signs were documented as heart rate 85, respirations 16, blood pressure 174/89, oxygen saturation of 93 percent on room air (no temperature), with a pain score of 10/10 by RN #40. At 0755 the CT of Abdomen and Pelvis (6 hours) resulted (7 hours and 27 minutes after ordered) positive for a small bowel obstruction.

Interview on 11/15/2023 at 1350 with ED RN #38 who triaged Patient #27 revealed "...in 2022 no patients were checked on in the ED waiting room, some changes were made, and there are some improvements. It's very possible that this patient waited without any completed. At that time there was one nurse in the waiting room to triage patients. There was no way to complete orders..." Interview revealed physician orders were not completed in the ED waiting room in 2022.

Interview on 11/15/2023 at 1414 with ED MD #26 revealed "...I saw the patient after she was roomed...There is not always a person to get labs and orders done. No staff to do orders. With the new process the goal is for that not to happen, but at night I suspect it does. As far as care in the waiting room, this patient didn't get vital signs, or overall assessments and no meds...things are not happening on a timely basis..." Interview revealed Patient #27 did not get medications as prescribed. Interview revealed hospital policy was not followed for Patient #27.




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6. Review on 11/16/2023 of "Nursing Management of Wounds and Alterations of Skin" policy revised 11/2021 revealed, "POLICY: Patients are assessed on admission and once every 12-hour shift for alterations in skin integrity and/or wounds. SCOPE:...Inpatient, acute care services, critical access hospitals, and other related services. Emergency Department (ED)...DOCUMENTATION: Document wound details: type, bed color, odor, drainage (color and amount), undermining/tunneling, induration, and erythema. Document intervention".

Review on 11/16/2023 of the "Assessment and Reassessment" policy revised 06/2021 revealed: "...PURPOSE: A. The goal of the assessment/reassessment is to provide the patient the best care and treatment possible...The nursing process is utilized in order to achieve this goal. This process includes assessing, analyzing, planning, implementing, and evaluating patient care or treatment...".

Closed medical record review on 11/14/23 of Patient #26 revealed a 22-year-old patient that presented to the Emergency Department (ED) via EMS (Emergency Management Services) on 09/01/2022 at 1845 for complaints of abdominal pain, decreased appetite, watery non-bloody diarrhea, and right-calf burn. Review of an ED Note dated 09/01/2022 at 2130 per medical provider indicated: "Assessment/Plan...Burn. I ordered bacitracin and instructed the nurse to apply a Xeroform dressing". Review of Patient #26's closed medical record lacked documentation that an ED nurse assessed and applied bacitracin and a Xeroform dressing to the patient's right-calf burn. Review revealed the patient was transferred to inpatient room #566 A5-West on 09/03/2022 at 1357. Review revealed a nursing wound consultation was completed on 09/04/2022 at 1024. Review of Inpatient Wound/Ostomy Documentation Note dated 09/04/2022 at 1024 indicated: "Wound care consult received for calf burn...wound is pink, red wound bed, superficial. Communicated with RN (Registered Nurse) that wound team will not be able to prioritize this patient today. Would recommend provider place order for bacitracin to be applied generously, cover with xeroform gauze, then dry gauze and gauze roll, daily. Will only follow if wound worsend with appropriate treament-please reconsult if this occurs". Review of a physician's order dated 09/04/2022 at 2100 indicated: "Bactroban topical 2% cream to be applied three times daily at 0900, 1500, and 2100 for 7 days to right-calf wound". Review revealed a lack of documentation related to the application of the aforementioned wound treatment per nursing. Review of the patient's closed medical record lacked nursing documentation related to the assessment and treatment of the patient's right calf wound from presentation in the ED on 09/01/2022 through discharge on 09/07/2022.

Based on review of hospital staff orientation/competency training, medical record review, and staff interviews, hospital staff failed to document baths and/ or linen changes had been performed to meet patient activity of daily living needs in seven (7) of 56 sampled inpatient patient records reviewed (Patient #'s 55, 64, 90, 81, 60, 40, and 26).

The findings included:

On 12/08/2023 at 0911 review of hospital documentation titled "Preceptor Guide Patient Care Tech (PCT) Staged Orientation" last updated 04/15/2022 revealed the "Preceptor Guide Provides detailed instructions for what the orientee must do for items to be checked off as 'met.'" Further review revealed the orientation stages ranged from 0 through 2. Stage 1 focused on basic patient care and procedures which included documentation. Stage 2 focused on "Routine Application: Provision of Patient Care" which included "Safely and reliably performs routine daily care for a variety of patient populations" and "Anticipates basic potential patient needs." Review revealed in stage 1 of orientation the orientee was expected to meet the following objectives: "Objective that needs to be Met ...Contributes to a healing environment ...Changes linen as indicated (includes occupied / unoccupied bed changes) ..." The orientee expected to meet "Documents activities / care in the EHR (Electronic Health Record) with preceptor assistance" which included "ADL (Activity of Daily Living". Stage 2 for routine application included "providing information related to ADLs and other care to patient ...Prepares in advance to answer questions about topics such as ADLs" Review revealed the skills with "(**)" indicated the skills "are essential items to onboarding and should be completed with orientee to successfully prepare them in patient care." Further review revealed the orientee assisted with ADLs which included "Hygiene Care** ...Bed bath, Shower and linen change."

On 12/08/2023 at 0911 review of hospital documentation titled "Preceptor Guide Medical Surgical RN Staged Orientation" last updated 04/15/2022 revealed the staged orientation grid was divided into stages 0 through 4. Stage 4 "Preceptor Guide Provides detailed instruction for what the orientee must do for items to be checked off as 'met'" Further review revealed in the "Stage 1 - SKILL BUILDING" the preceptor was to "show" the orientee "how to document routine Activities of Daily Living (ADLs) in the EHR."

On 12/08/2023 at 0911 review of hospital documentation titled "New Employee Orientation" module revealed "Cerner (hospital electronic system) Training for the PCT included "Documenting ADL's"

1. Closed medical record review on 12/05/2023 for Patient #55 revealed on 05/17/2023 at 1638 a 74 year old male arrived in the ED with SOB (shortness of breath). The admission H&P dated 05/17/2023 at 2100 by NP #29 revealed Patient #55 was seen earlier the same day at an outside hospital. The H&P included sarcoidosis diagnosed two years ago and during the last 3-4 days Patient #55 experienced a productive cough with increased SOB. The patient was transferred from the ED to a Medical Surgical Unit room 445 and remained assigned to the room until discharge on 06/06/2023 at 1115. Review revealed there was no documentation that Patient #55 was provided, offered or refused a bath for 16 days or that Patient #55 was provided, offered or refused linen changes x 14 days.

On 12/05/2023 request made to interview CNA that provided care for Patient #55. On 12/06/2023 at 1115 it was revealed the CNA was not available.

Interview on 12/06/2023 at 1320 with Nurse Manager (NM) #32 revealed staff were expected to offer baths every twenty-four hours, per patient's request and as needed. Interview revealed staff was expected "to document" performed ADLs.

Interview on 12/08/2023 at 1403 with (Certified Nurse Aide) CNA #33 revealed she offered baths every day and as needed. She stated "especially" if the patient was able to take a shower. CNA #33 revealed she charted when the task was done.

Interview on 12/08/23 at 1448 with CNA #34 revealed patient baths can be given day or night shift. She revealed she checked the chart at the beginning of her day shift to see the number of patients that needed baths. Interview revealed that CNA #34 documented baths right away once done but if she did not have time, she would write the task down on paper and document the task later.

Interview on 12/08/2023 at 0911 with the Director of Clinical Education (DCE) #36 revealed PCT was the same as CNA. She revealed there was not a policy regarding when baths or a change of linen was offered. She revealed that upon hire PCTs were oriented by preceptors which included baths, linen change and documentation once the task was completed. The orientation continued on the assigned unit and a face-to-face with the hospital EMR (Electronic Medical Record) system. DCE #36 stated "the annual competencies may not be the same for each unit because it depends on the needs of that unit."

2. Closed medical record review on 12/06/2023 for Patient #64 revealed on 08/30/22 at 1547 a 36 year old male arrived in the ED with upper back pain. Review of a progress note dated 08/31/2023 at 1240 by PA #31 revealed per a Radiologist Patient #64 had osteomyelitis to C6-C7 with discitis (inflammation to the disc between the spinal vertebrae - bones). An epidural abscess was present with spinal cord compression that extended from CT to T1 (pressure to the top of the neck-cervical segment to the thoracic segment - chest portion of the spinal cord). A neurosurgery consultation was made for likely urgent surgical intervention. Further review revealed on 08/31/2022 Patient #64 had an emergency "Anterior Cervical Discectomy" spinal surgical procedure. Review of a progress note dated 12/12/2022 at 1419 by an ID (infectious disease) MD revealed Patient #64 remained "profoundly debilitated and with neurologic deficits; he is currently paraplegic but also has upper extremity strength issues." Patient # 64 was assigned to the Pulmonary unit Date: 10/09-15/2022. Review revealed there was no documentation the patient was offered or refused linen changes x 6 days. Patient #64 was assigned to the K-Spine unit, Date: 10/19-26/2022. Review revealed there was no documentation that Patient #64 was provided, offered or refused a bath x 6 days or that Patient #64 was provide, offered or refused a linen change x 5 days for sample week. Patient #64 was assigned to a Med Surg/Telemetry unit, Date: (11/13-19/2022) and (12/25-31/2023) and the patient required total assistance. Review revealed there was no documentation that Patient #64 was provided, offered, or refused baths x 6 days or was provided, offered or refused a linen change x 4 days for the first sample week. Review revealed there was no documentation that Patient #64 was provided, offered or refused baths x 5 days or was provided, offered or refused linen change x seven days for the second week. Patient #64 was assigned to the Neuro unit, Room A611, Dates: 01/06-31/2023 and 02/19-25/2023. Review revealed there was no documentation that Patient #64 was provided, offered or refused a bath x 23 days or provided, offered or refused linen changes x 5 days for the first sample week. Review revealed there was no documentation that Patient #64 was provided, offered or refused baths x 5 days or provided, offered or refused linen changes for the second sample week.

Interview on 12/06/2023 at 1320 with Nurse Manager (NM) #32 revealed staff were expected to offer baths every twenty-four hours, per patient's request and as needed. Interview revealed staff was expected "to document" performed ADLs.

Interview on 12/08/2023 at 1403 with (Certified Nurse Aide) CNA #33 revealed she offered baths every day and as needed. She stated "especially" if the patient was able to take a shower. CNA #33 revealed she charted when the task was done.

Interview on 12/08/23 at 1448 with CNA #34 revealed patient baths can be given day or night shift. She revealed she checked the chart at the beginning of her day shift to see the number of patients that needed baths. Interview revealed that CNA #34 documented baths right away once done but if she did not have time, she would write the task down on paper and document the task later.

Interview on 12/08/2023 at 0911 with the Director of Clinical Education (DCE) #36 revealed PCT was the same as CNA. She revealed there was not a policy regarding when baths or a change of linen was offered. She revealed that upon hire PCTs were oriented by preceptors which included baths, linen change and documentation once the task was completed. The orientation continued on the assigned unit and a face-to-face with the hospital EMR (Electronic Medical Record) system. DCE #36 stated "the annual competencies may not be the same for each unit because it depends on the needs of that unit."



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3. Review of closed medical record revealed Patient #90, a 57 year old female arrived to the hospital on 07/05/2022 for a scheduled surgical total hip arthroplasty (total hip surgical replacement) for continued failed treatment for hip osteoarthritis (degeneration of cartilage and the underlying bone). Review of physician post-surgical orders revealed Patient #90 could shower after surgery. Review of documentation of baths revealed Patient #90 did not receive a bath or shower on 07/06/2022, 07/07/2022, 07/08/2022, 07/09/2022, 07/10/2022, and 07/11/2022, a total of 6 days. Patient #90 was discharged on 07/13/2022.

Interview on 12/06/2023 at 1320 with Nurse Manager (NM) #32 revealed staff were expected to offer baths every twenty-four hours, per patient's request and as needed. Interview revealed staff were expected "to document" performed ADLs (activities of daily living--baths or showers).



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4. Closed medical record review revealed Patient #81 was admitted on 09/20/2023 at 1445 with a presenting chief complaint of shortness of breath. Review of the Nursing Flowsheet, revealed on 09/20/2023 no evidence of assistance with activities of daily living on the Medical Cardiology Stepdown unit when patient arrived onto the unit at 2144. On 09/21/2023 review failed to reveal evidence of a bath offer/decline or linens changed. On 09/22/2023 review failed to reveal evidence of a bath offer/decline or linens changed. On 09/23/2023 review failed to reveal evidence of a bath offer/decline or linens changed. On 09/24/2023, 0700 through 1900 (12 hours), RN #4 provided primary nursing care to Patient #81, which failed to reveal evidence of a bath offer/decline or linens changed. On 09/26/2023 review failed to reveal evidence of a bath offer/decline or linens changed. Patient #81 was discharged on 09/26/2023 at 0759 to the skilled nursing facility.

Interview with an RN #82 on 12/05/2023 at 1115 revealed, it was the expectation of the facility staff to document that patients were offered or declined daily hygiene opportunities and linen changes in the medical record every 24 hours.

Interview with RN #4 on 12/07/2023 at 0955 revealed, it was the expectation of the facility staff that patients were to be offered and documented daily hygiene opportunities and linen changes in the medical record every 24 hours. Interview revealed it was the Registered Nurse to oversee the completion of the task of bathing opportunities, linens changed as part of activities of daily living.



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5. Review on 11/28/2023 of the closed medical record for Patient #60 revealed a 63-year-old female that presented to the Emergency Department on 10/31/2022 at 1101 with a chief complaint of chest pain. Patient #60 was admitted to inpatient services on 10/31/2022 at 1646 and discharged on 11/18/2022 at 1556. Review of the nursing notes from 10/31/2022 through 11/18/2022 revealed that Patient #60 was assisted with a bath on 11/03/2022, refused bath on 11/04/2022 and 11/15/2022, basin wipes bath on 11/16/2022 and performed bath independently on 11/17/2022. Documentation failed to reveal evidence that Patient #60 received a bath on 11/01, 11/02, 11/05, 11/06, 11/07, 11/08, 11/09, 11/10, 11/11, 11/12, 11/13, 11/14 and 11/18/2022 (13 of 18 days with no documented bath).

Interview on 12/01/2023 at 0945 with NM #85 and NM #86 revealed the staff were expected to document that patients were offered or refused a daily bath in the medical record every 24 hours.



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7. Review on 11/16/2023 of the "Staffing Responsibilities and Procedure" policy revised 02/10/2015 revealed, "Policy: Mission Hospital will maintain staffing to meet patient care needs on all nursing units...".

Closed medical record review on 11/14/23 of Patient #26 revealed a 22-year-old patient presented to the Emergency Department (ED) via EMS (Emergency Management Services) on 09/01/2022 at 1845 for complaints of abdominal pain, decreased appetite, watery non-bloody diarrhea, and right-calf burn. Review revealed the patient was transferred from the ED to unit B3-South (3rd floor holding area) on 09/02/2022 at 1915. Review of closed medical record lacked nursing documentation related to patient assistance with toileting while located on unit B3-South from 09/02/2022 through 09/03/2022. Review revealed the patient was transferred from unit B3-South to unit A5-West room #566 on 09/03/2022 at 1357. Review of closed medical record lacked nursing documentation related to patient assistance with bathing (shower/bath) and hygiene needs from 09/03/2022 through 09/07/2022.

Interview on 11/14/2023 at 1545 with RN #101 revealed unit B3-South (3rd floor holding area) is currently not being utilized as a patient care unit. RN #98 revealed during Patient #26's hospital admission starting on 09/02/2022, unit B3-South was a "holding unit" for patients between the ED and admission to an inpatient bed. RN #98 revealed patient rooms on the unit did not have bathrooms in the rooms and patients would have to walk to a bathroom located in the hallway. RN #98 revealed nursing staff should have assisted patients with toileting and/or ambulating to the hallway bathroom.

Interview on 11/16/2023 at 1130 with PCT #99 (Patient Care Technician) while on tour of unit A5-West indicated that he/she assists patients with ADL's (Activities of Daily Living) such as bathing, toileting, and oral care. PCT #99 stated that patients located in even room numbers are assisted with bathing on the dayshift and patients located in odd room numbers are assisted with bathing on the nightshift. PCT #99 stated the unit is often staffed with 1 PCT for up to 36 patients making it difficult to provide care in a safe and timely manner to all patients.

Interview on 11/16/2023 at 1200 with RN #97 (Director) indicated unit A5-West has 36 patient beds which ideally was staffed with 7 RN's, 2 PCT's and 1 unit clerk. RN #97 revealed fully staffing the unit was often a challenge.




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6. Closed medical record review on 11/14/23 for Patient #40 revealed on 3/4/2023 at 1747 an 84 year old male with a history of Alzheimer's presented with increasing weakness and confusion. Patient #40 remained in the Emergency Department (ED) until being admitted from 3/5/23 at 0216 until discharge to a nursing facility on 3/8/23 at 1722. There was no documentation to reflect an offer/decline of a bath during this 4-day time period.

Closed medical record review on 11/14/23 for Patient #40 revealed on 4/28/23 at 0226 the 84-year-old male with a history of Alzheimer's was transported to the ED via ambulance after falling at a local pharmacy. Patient #40 was diagnosed with COVID requiring supplemental oxygen then admitted to the facility on 4/29/23 at 0709. Patient #40 remained in the facility until discharge to a nursing facility on 5/9/23 at 1021. There was no documentation to reflect an offer/decline of a bath for the 11-day admission. During the same 11-day admission, there were no documented linen changes with the exception of "no" being documented on 5/5/23 at 0442 and 2000.

Interview with RN #81 on 11/14/23 at 1200 confirmed the expectation for nursing to offer and document bathing and linen changes in the medical record.
.

Based on policy review, medical record reviews, and staff interviews the hospital failed to have available, adequate laboratory services to meet the needs of patients for three (3) of 35 patients presenting to the hospital's Emergency Department (ED) (Patient #'s 83, 27 and 2) and failed to ensure laboratory results were timely for three (3) of three (3) patients (Patient #'s 11, 93, and 94).

The findings included:

The hospital failed to have available laboratory services to meet the identified turn around times for STAT results for three (3) of 35 patients presenting to the hospital's emergency department (Patient #'s 83, 27, and 2), and failed to ensure timely laboratory results for three (3) of 3 patients that had lab specimens sent to Hospital A's lab from Hospital B (Patient #'s 11, 93 and 94).

Cross refer to §482.27 Laboratory Services Standard: Tag A 0583.

Based on policy review, medical record review, incident report review, laboratory logs, documents and staff interview, the hospital failed to have available laboratory services to meet the identified turn around times for STAT (immediate) results for three (3) of 35 patients presenting to the hospital's Emergency Department (ED) (Patient #'s 83, 27, and 2), and failed to ensure timely laboratory results for three (3) of three (3) patients that had lab specimens sent to Hospital A's lab from Hospital B (Patient #'s 11, 93 and 94).

The findings included:

A. Review on 11/17/2023 of the hospital policy Turn Around Time, last revised 11/17/2021 revealed "...PURPOSE: To provide timely and efficient testing services for routine, critical and high-risk situations. DEFINITIONS: Turn Around Time (TAT): the time elapsed from order placement to result reporting. Categorized as: Pre-analytical Phase: the period between test order entry by the caregiver and specimen receipt in the Laboratory. May be influenced, but not controlled by the Laboratory. Analytical Phase: the period between specimen receipt in the Laboratory and result reporting. Controlled by the Laboratory...STAT: an emergent, potentially life-threatening request. NOW: as soon as possible. Synonymous with ASAP. POLICY: All tests will be performed without delay to maximize specimen quality and integrity. STAT, NOW ... requests will be managed as priority situations. First-in, First-out (FIFO) processes are utilized to facilitate rapid and efficient movement of specimens through the system. Requests are also prioritized based on the following criteria to meet defined turn-around times: ...Response to STAT requests: ...STATS take priority over other specimens and should be managed from time of receipt until result reporting with no interruption in handling or testing. In general, the maximum TAT for most tests is 45-50 minutes from order receipt.... Response to NOW/ASAP requests: ...Staff will immediately process the specimen, perform testing, and verify results. Results should be available within (1) one hour from specimen receipt.... TAT Summary (Inpatient): STAT, Time from ORDER Receipt 45-50 minutes. NOW, Time from SPECIMEN receipt 1 hour..."

1. Closed medical record review on 12/06/2023 revealed Patient #83, a 74-year-old female patient who arrived at the emergency department (ED) with dizziness on 11/28/2023 at 1216. The patient had STAT lab work ordered at 1218. Labs were drawn at 1358. Labs arrived at the lab at 1412 and resulted at 1532 (1 hour and 20 minutes after arriving to lab, 3 hours and 14 minutes after ordered). The blood glucose was 1137 (critically high). Lactic acid was ordered NOW at 0127 for nurse collect in the ED. At 0200 a physician wrote there was a delay in labs and fluids so stopped the insulin IV infusion. At 0529 the original lactic acid NOW, order was canceled and reordered as lab collect NOW on the floor. It was collected at 0844 (3 hours and 15 minutes after ordered at 0529) and resulted at 1108 (9 hours and 41 minutes after originally ordered at 0127) with a result of 7.48 critical high. A second lactic acid was reordered at 1108 and resulted at 1256 (1 hr. and 36 after ordered) with a result of 11.96 critically high. A rapid response was called previously at 1158, the patient was intubated at 1247, and ultimately expired on 11/30/2023.

Review of Patient Safety Analysis completed by RN #12 on 12/01/2023 at 1917 revealed this Care Event was a "Delay in Care" and the issue was "Lack of timely response to Order", for Patient #83. A description "A NOW LA (lactic acid) order was placed at 0529. Lab wasn't drawn until 0844, and in lab at 0907. Critical results of lactic acid 7.48 reported at 1108. MD at 1114...Shortly after this (within the hour), the patient took a turn and had to be intubated at bedside and sent to ICU (intensive care unit) ...Solution to Prevent this from Recurring? Promptly follow orders..." This Patient Safety Report was still in process. Review of the report revealed Patient #83 had a delay in lab work.

Telephone interview on 12/07/2023 at 1632 with RN #10 who cared for Patient #83 in the Orange Pod revealed "...I work on an inpatient unit and was pulled to the ED that day. It's a revolving door, I don't recall this patient in particular. If I can't get the labs, I would call a phlebotomist after 3 tries to get the labs if I couldn't..." Interview revealed she could not remember why the NOW lactic acid order was not collected. Interview revealed physician orders for Patient #83 were not followed.

Interview on 12/08/2023 at 0915 with RN #11 revealed she did remember Patient #83 and worked night shift. "...I did not receive a report on this patient from the ED. You have to look up the medical record number and sometimes the charge nurse gets an alert that the patient is coming and will print the face sheet. I had to piece it together and go through the orders. I reordered the lab work when I saw it was pending. My concern is we have trouble getting in contact with the phlebotomist. That morning they were not logged into to their IMobile device. I called the general lab number, and no one answered. I then contacted my house supervisor, and he told me 'we don't have another option right now.' I can't recall if she was on a telemetry box or not, I was only with her over an hour..." Interview revealed not being able to reach a phlebotomist during night shift had happened before. Interview revealed RN #11 had called multiple times to reach the lab phlebotomist to draw NOW blood orders without reaching someone. Interview revealed lab Turn Around Time for NOW lab orders was not followed for Patient #83.

Interview on 12/08/2023 at 1309 with Laboratory Phlebotomist Supervisor #17 revealed "...the phlebotomists do not collect in the ED; we will help if called. All labs ordered in the ED default to "nurse collect". The expectation was for STAT and NOW orders to be from order to collection in 15 minutes and to be resulted in an hour from order..." Interview revealed lab collection for STAT and NOW orders for Patient #83 did not follow hospital policy.

Interview on 12/09/2023 at 1159 with Lab Director #18 revealed "...I do know we had a call out that day. The lactic acid was available for the lab tech to see at 1016 but wasn't called to the floor until 1108. I don't know what the delay was. The expectation was to call as soon as the result was available. The expectation for lab collection and processing was to follow the policy guidelines, and for STAT and NOW results to be completed within an hour..." Interview revealed lab collection and processing did not follow hospital policy for Patient #83.

2. Closed medical record review revealed Patient #27 arrived in the ED on 07/04/2022 at 0025 with abdominal pain reported as a pain level of 10 of 10. Orders for STAT lab work were placed at 0028. Lab results were completed at 0734 (7 hours and 6 minutes after ordered). The patient was diagnosed with a small bowel obstruction and had surgery that day. The patient had a delay with STAT lab work.

Interview on 11/15/2023 at 1350 with ED Registered Nurse (RN) #38 who triaged Patient #27 revealed "... It's very possible that this patient waited without any labs or orders completed. At that time there was one nurse in the waiting room to triage patients. There was no way to complete orders..." Interview revealed physician orders were not completed in the ED waiting room.

Interview on 11/15/2023 at 1414 with ED Medical Doctor (MD) #26 revealed "...I saw the patient after she was roomed.... There is not always a person to get labs and orders done. No staff to do orders. With the new process the goal is for that not to happen, but at night I suspect it does. ... things are not happening on a timely basis..." Interview revealed hospital policy was not followed for Patient #27.



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3. Review of the medical record, on 11/14/2023, revealed Patient #2 arrived to the hospital on 10/17/2023 at 1753 via EMS. Review of "ED Triage", performed 10/17/2023, at 1900 (1 hour and 7 minutes after arrival) revealed a pre-hospital blood glucose of 459 and an acuity of "3-urgent".

Review of the "ER Report" by a Physician Assistant, on 10/17/2023 at 1845, revealed "... 66-year-old male patient .... presents.... (to the) emergency department today via EMS for chief complaint of chest pain and shortness of breath. ED record review revealed the following lab tests were ordered in the ED stat at 1841 (48 minutes after Patient #2 arrived): Lactic Acid, CMP (comprehensive metabolic panel), Troponin, D-Dimer, Pro B-Type Natriuretic Peptide (ProBNP) and CBC with Differential. Review of orders revealed the labs were collected as Nurse collects at 1920 (39 minutes after the lab orders). Patient #2 experienced cardiac arrest at 1953, 2 hours after arrival. The CBC resulted at 2002 and the CMP resulted at 2012. The D-Dimer resulted as 824 (high) at 2006. The Pro BNP resulted as 9690 (High - reference range 5-125) at 2023 and the Troponin resulted as 0.460 (High - reference range 0.000-0.034) at 2039 (1 hour 19 minutes after the lab was collected; 1 hour, 58 minutes after it was ordered). The physician was notified. Review revealed the physician was notified 2 hours, 46 minutes after Patient #2 arrived to the ED and 15 minutes after the patient expired). Review revealed delays in ordering, collecting and resulting the labs.

Interview on 12/08/2023 at 1309 with Laboratory Phlebotomist Supervisor #17 revealed "...the phlebotomists do not collect in the ED; we will help if called. All labs ordered in the ED default to "nurse collect". The expectation was for STAT and NOW orders to be from order to collection in 15 minutes and to be resulted in an hour from order..."

Interview on 12/09/2023 at 1159 with Lab Director #18 revealed "...The expectation for lab collection and processing was to follow the policy guidelines, and for STAT and NOW results to be completed within an hour..."



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B. Review of policy Microbiology Turn Around Times, Effective 05/30/2023, revealed "...III. POLICY A. Microbiology services are available 24/7. B. Specimens are received and processed on all 3 shifts. Microbiology Department: Test menu and turnaround time information...17. Urine Culture a. Negative Culture: i. Non-invasive (i.e. clean catch & indwelling cath): 18-24 hours ii. Invasive: 48 hours b. Positive Culture: 24-48 hours ..."

Review on 11/15/2023 of lab work sent to Hospital A from Hospital B as an outpatient lab service for Patient #11 revealed that a urine culture was submitted on 09/14/2023. The positive results were released on 09/19/2023 (four days after the specimen was received in the lab).

Review on 11/15/2023 of lab work sent to Hospital A from Hospital B as an outpatient lab service for Patient #94 revealed that a urine culture was submitted on 09/06/2023. The positive results were released on 09/12/2023 (six days after the specimen was received in the lab).

Review on 11/15/2023 of lab work sent to Hospital A from Hospital B as an outpatient lab service for Patient #93 revealed that a urine culture was submitted on 09/18/2023. The positive results were released 09/23/2023 (five days after the specimen was received in the lab).

Review on 11/16/2023 of a log of all urine cultures processed by the Microbiology section from 09/23/2023 through 09/30/2023 revealed that 14 of 29 cultures, or 48%, were resulted at greater than 48 hours.

Review of an email from a Laboratory Microbiology Manager on 11/15/2023 at 1121 revealed "...There were delays in getting these finalized due to critical staffing in Microbiology. The decision was made on 09/19/2023 to start sending all of (named Hospital) to (Named outpatient Laboratory Company) since we didn't have the staff to read all cultures. The staff had to prioritize cultures. Outpatients were not looked at on a daily basis. They had to prioritize inpatients and critical specimen types such as blood cultures. However, they did sub the organisms each day to make sure they were viable to do identification and susceptibility testing."

Request for interview with the Laboratory Microbiology Manager revealed they were unavailable.

Telephone interview on 11/17/2023 at 0959 with the North Carolina Division Director of Laboratory revealed that during September 2023, the hospital microbiology department was experiencing critical staffing problems due to vacancies and staff on medical leave. The Director stated that on 10/02/2023, it was decided to use an outside Laboratory company to handle microbiology cultures. The Director also stated that at the same time, the department focused on staffing, hiring travelers and training on new processes. The Director stated that on November 6th, 2023, the hospital inpatient cultures were returned to in-house processing. The Director stated the Quality dashboards were being created to monitor turnaround times for cultures going forward.

Based on policy review, medical record review, incident report review, Emergency Medical Services (EMS) trip report review, and staff and provider interviews, the hospital staff failed to have effective emergency services to meet the needs of patients that presented to the Emergency Department.

The findings included:

Emergency Department (ED) nursing staff failed to ensure emergency care and services were provided according to policy and provider orders by failing to accept patient upon arrival to the ED, evaluate, monitor and provide treatment to emergency department patients to prevent delays and/or lack of triage, nursing assessment, and implementation of orders, including lab, telemetry and medication orders for eleven (11) of 35 patient records reviewed (Patient #'s 92, 83, 43, 28, 27, 29, 6, 1, 2, 12 and 26).


Cross refer to §482.55 Emergency Services Standard: Tag 1101.

Based on policy review, medical record review, incident report review, EMS trip report review, and staff and provider interviews, Emergency Department (ED) nursing staff failed to ensure emergency care and services were provided according to policy and provider orders by failing to accept patients upon arrival to the ED, evaluate, monitor and provide treatment to emergency department patients to prevent delays and/or lack of triage, nursing assessment, and implementation of orders, including lab, telemetry and medication orders for eleven (11) of 35 patient records reviewed (Patient #'s 92, 83, 43, 28, 27, 29, 6, 1, 2, 12 and 26).

The findings included:

Review on 12/06/2023 of the hospital policy "Triage - Emergency Department 1PC.ED.0401" revised 07/2023 revealed, "...DEFINITIONS: ... A. Triage Assessment: The dynamic process of sorting, prioritizing, and assessing the patient and is performed by a qualified RN (Registered Nurse) at the time of presentation and before registration. This is a focused assessment based on the patient's chief complaint and consists of information, which is obtained that would enable the Triage RN to determine minimal acuity. A rapid or comprehensive triage assessment is completed, with a goal of 10 minutes, on arrival to the emergency department. 1. A rapid triage assessment is composed of airway, breathing, circulation and disability, general appearance, eliciting symptom driven presenting complaint(s), and any pertinent objective and subjective data/assessment from the patient or parent or caregiver. 2. A comprehensive assessment, performed on each patient that presents to the emergency department, is a focused physical assessment including vital signs, pain scale, allergy, history of current complaint, current medications, exposure to infectious disease, and pertinent past medical/surgical history. ... B. Triage Acuity Level - The Emergency Severity Index (ESI) is a five level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs. C. Reassessment - A process of periodic re-evaluation of the patient's condition and symptoms prior to and during the initiation of treatment. Reassessment components may include some or all of the following: vital signs, a focused physical assessment, pain assessment, general appearance, and/or responses to interventions and treatments. Reassessment after the medical screening exam are performed by RN's (Registered Nurses) according to acuity or change in patient's condition. D. Vital Signs - Helps nursing personnel determine the stability of patients and acuity of those that are that are presenting with life-threatening situations or who are in high-risk categories. Usually refers to temperature, pulse rate, respiratory rate, and blood pressure. May include pulse oximetry for patients presenting with respiratory and/or hemodynamic compromise, and pain scale for those patients with pain as a component to their presenting complaint...PROCEDURE: ...B. All patients presenting for care will be evaluated by an RN. This RN should complete a brief evaluation of the patient, including immediate compromise to a patient's airway, breathing, or circulation.... H. If there is no bed available, the patient will need to wait in the lobby. While in the lobby, patient reassessment and vital signs should be documented in the health record in accordance with documentation guidelines. ..."

Review on 12/09/2023 of the "Assessment and Reassessment" policy revised 06/2021 revealed, "... PURPOSE: A. The goal of the assessment/reassessment is to provide the patient the best care and treatment possible ... The nursing process is utilized in order to achieve this goal. This process includes assessing, analyzing, planning, implementing and evaluating patient care or treatment. ... DEFINITIONS: A. Assessment: The multidisciplinary assessment process for each patient begins at the point where the patient enters a (facility name) facility for care, and in response to changes in the patient's condition. ... The assessment will include systematic collection and review of patient-specific data necessary to determine patient care and treatment needs. B. Reassessment: The reassessment process is ongoing and is also performed when there is a significant change in the patient's condition or diagnosis and in response to care. ... SECTION VI: EMERGENCY DEPARTMENT: A. Patients should be triaged following guidelines set forth in the system Triage Policy (1PC.ED.0401), including documentation of required elements within the electronic medical record (e.g. Vital signs, Glasgow Coma Scale (GCS)). B. The priority of data is determined by the patient's immediate condition. On arrival to unit, an initial assessment is initiated and immediate life-threatening needs are determined with appropriate interventions implemented. C. Patient assessment should be performed based on the developmental, psychosocial, physiological, and age-specific needs of the individual. D. Focused patient history and physical assessment are based on patient's presenting problem(s) including individual indicators of vulnerability. E. Reassessment: 1. Reassessment is ongoing and may be triggered by key decision points and at intervals based on the needs of the patients. Additional assessment/reassessment elements and frequency are based upon patient condition or change in condition, diagnosis, and/or patient history, not to exceed four hours. Interventions may warrant more frequent assessments...."

1. Closed medical record review on 12/09/2023 of Patient #92 revealed a 69 year-old male that presented to the emergency department on 11/09/2023 at 1149 via private vehicle with a chief complaint of chest pain. The patient was triaged at 1155 with a chief complaint of "Woken from sleep at 0400 with midsternal chest pain, described as sharp and pressure. No SOB (shortness of breath), arm/jaw/back pain, or diaphoresis (sweating). H/o (history of) colon CA (cancer) with mets (metastasis) to the lung, currently on chemotherapy...." Review revealed vital signs of blood pressure (BP) 125/60, pulse (P) 57, temperature (T) 97.4 degrees Fahrenheit, oxygen saturation (O2 Sat) 97% and a pain level reported as 2 (scale 1-10 with 10 the worst). Review revealed a triage level of 2 (level 1 most urgent). Review revealed a Medical Screening Examination by a physician was started in the waiting room area at 1209. Review of the physician's notes recorded the patient's chest pain had been waxing and waning, coming in waves and lasting about five minutes at a time. Review revealed a plan to conduct an ED chest pain work-up including a chest x-ray, EKG and labs including CBC, chemistry, lipase and troponin, and administer a dose of aspirin. Review recorded a differential diagnosis of GERD (gastroesophageal reflux disease), referred abdominal pain, musculoskeletal chest pain, ACS (acute coronary syndrome), with lower suspicion for PE (pulmonary embolus) given no tachycardia, hypotension, or evidence of DVT (deep vein thrombosis) on exam. Review revealed the ED physician recommended admission for further chest pain workup based on risk factors. Review of physician's orders revealed labs were ordered at 1218, collected at 1320 and resulted at 1332. Review revealed a troponin result of 0.013 (normal). Review revealed a physician's order placed at 1218 for continuous ECG (telemetry) monitoring in the ED. Review of the ED record revealed no evidence that continuous ECG monitoring was initiated in the ED. A chest x-ray was ordered at 1220 and resulted at 1246 with normal results. An EKG was completed at 1224 which showed sinus rhythm with premature atrial complexes (PACs), with no changes when compared with a prior EKG done in 2022 per the physician's read. A troponin resulted at 1320 as 0.013 (normal) and a baby aspirin was administered as ordered at 1334. A second troponin ordered at 1607 and resulted at 1704 as 0.014 (normal). Review of a second EKG completed at 1628 revealed "Sinus rhythm with premature atrial complexes (PACs). Otherwise normal ECG. When compared with ECG of 09-Nov-2023 12:24, Non-specific change in ST segment in inferior leads. ST elevation now present in Lateral leads." Review recorded the ECG was confirmed by a physician on 11/09/2023 at 1821. Review revealed a physician's order at 1659 for nitroglycerine 0.4 milligrams (mg) sublingual every five minutes times three as needed (prn) chest pain. Record review revealed no nursing assessment/reassessment documented after the patient's triage was recorded at 1155. The patient was administered Morphine (narcotic pain medication) 2 milligrams intravenously (IV) at 1703 by a medic for a pain level of 4. There was no reassessment of the patient's pain and no documentation of the patient's condition by a nurse. The patient was moved from the waiting room to a bed in the orange pod (admission holding area of the ED) at 1937. Nitroglycerine 0.4 milligrams sublingual was administered by a nurse times one for a pain level of 10 at 2013. Review revealed no reassessment of the patient's response to the medication intervention and no nursing assessment of the patient's condition was documented. The patient was transported from the ED to a medical surgical floor on 11/09/2023 at 2054. The patient was placed on continuous telemetry at 2111 when he was noted to be in Atrial Fibrillation with Rapid Ventricular Rate (abnormal heart rhythm). Review of the ECG completed at 2110 recorded an "ST elevation consider lateral injury or acute infarct ** ** ACUTE MI / STEMI (myocardial infarction or heart attack) ** ** ...". Review of a Cardiovascular Consult History and Physical documented on 11/10/2023 at 0020 as an Addendum revealed the patient "... went into AF/RVR (Atrial Fibrillation with Rapid Ventricular Rate) at 2110 hrs this evening with ECG demonstrating evolving high lateral STEMI (l, aVL) which was more pronounced on follow-up ECG at 2210 hrs prompting formal STEMI activation for emergent cardiac catheterization. ..." Review of a Discharge Summary dated 11/13/2023 at 1211 revealed the patient was discharged home on 11/13/2023 with a diagnosis of STEMI (ST elevation myocardial infarction), Coronary Artery Disease, Hypertension, and Atrial Fibrillation with RVR.

Interview on 12/09/2023 at 1210 with ADON #17 revealed Patient #92 was identified as a level 2 triage and should have been assessed every four hours at a minimum, every two hours for a level two and with any change in the patient's condition. Interview revealed the patient developed chest pain and required interventions and no nursing assessments or reassessments were documented in the ED record. Interview revealed continuous telemetry was ordered for the patient at 1218 and telemetry was not placed on the patient in the ED. Interview revealed the telemetry was placed on the patient at 2111 once the patient transferred to the medical floor.

Patient #92 presented to the ED with chest pain on 11/09/2023 at 1149. The patient was not assessed by a nurse after triage was completed at 1155, or with a change in condition, or after pain medication was administered at 1703. The patient was never placed on continuous telemetry in the ED as ordered by a physician at 1218. The patient was transferred to a medical floor and placed on telemetry at 2111 when he was found to be in atrial fibrillation with rapid ventricular rate, prompting a STEMI Code Activation. The patient underwent an emergency cardiac catheterization at 2249. ED nursing staff failed to provide ongoing assessment of the patient's condition and follow physician's orders for application of continuous telemetry. Nursing staff failed to ensure policies and provider orders were implemented.



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2. Review on 11/17/2023 of the hospital policy Turn Around Time, last revised 11/17/2021 revealed "...PURPOSE: To provide timely and efficient testing services for routine, critical and high-risk situations. DEFINITIONS: Turn Around Time (TAT): the time elapsed from order placement to result reporting. Categorized as: Pre-analytical Phase: the period between test order entry by the caregiver and specimen receipt in the Laboratory. May be influenced, but not controlled by the Laboratory. Analytical Phase: the period between specimen receipt in the Laboratory and result reporting. Controlled by the Laboratory...STAT: an emergent, potentially life-threatening request. NOW: as soon as possible. Synonymous with ASAP. POLICY: All tests will be performed without delay to maximize specimen quality and integrity. STAT, NOW ... requests will be managed as priority situations. First-in, First-out (FIFO) processes are utilized to facilitate rapid and efficient movement of specimens through the system. Requests are also prioritized based on the following criteria to meet defined turn-around times: ...Response to STAT requests: ...STATS take priority over other specimens and should be managed from time of receipt until result reporting with no interruption in handling or testing. In general, the maximum TAT for most tests is 45-50 minutes from order receipt.... Response to NOW/ASAP requests: ...Staff will immediately process the specimen, perform testing, and verify results. Results should be available within (1) one hour from specimen receipt.... TAT Summary (Inpatient): STAT, Time from ORDER Receipt 45-50 minutes. NOW, Time from SPECIMEN receipt 1 hour..."

Closed medical record review on 12/06/2023 revealed Patient #83, a 74-year-old female patient who arrived at the emergency department (ED) via emergency medical services (EMS) on 11/28/2023 at 1216 with a chief complaint of dizziness from her doctor's office. Patient #83 was seen by an ED MD #1 on arrival and at 1218 a comprehensive metabolic panel (CMP) [includes serum glucose] was included in laboratory tests ordered as STAT (an emergent, potentially life-threatening request) with continuous ECG monitoring. At 1259 Patient #83 was placed in Red Pod (for the most acute patients) Hallway Bed-17. At 1309 the first set of vital signs was recorded by RN #2 as temperature 98.7, heart rate 84, respirations 19, blood pressure 225/88, and oxygen saturation of 93 percent on room air. At 1316 RN #3 completed a nursing triage assessment and Patient #83 was given an emergency severity index (ESI) [level 1 as the most urgent and 5 as the least urgent] of 3-urgent. Review of the CMP history revealed the STAT lab was collected at 1358 by RN #3 (1 hour and 40 minutes after the order was placed), the blood specimen arrived at the laboratory at 1412, and resulted at 1532 (3 hours and 14 minutes after the STAT order was placed) with a serum glucose resulted of 1137 (high normal range 120). Review of the Physician's Order on 11/28/2023 at 1626 by ED Nurse Practitioner (NP) #5 revealed a new order for an Insulin (IV medication to reduce serum glucose) IV infusion to be started (54 minutes after the glucose had resulted). At 1709 an Insulin drip was initiated for Patient #83 by the RN #3. At 1739, the Hospitalist NP #6 placed a continuous telemetry monitoring order for 48 hours for Patient #83, with vital signs every 2 hours while in the ED. At 1908 ED MD #14 ordered a Glycosylated Hemoglobin NOW that was collected at 2128 (2 hours after ordered). At 2109 Patient #83 was moved to the ED Holding-Orange Pod-Room-2 awaiting an inpatient bed. At 2329 Hospitalist MD #9 ordered an IV infusion of D51/2 NS with KCL (Dextrose, Normal Saline, and Potassium Chloride Solution). On 11/29/2023 at 0127 MD #9 ordered a Lactic Acid (carries oxygen from your blood to other parts of your body) level to be drawn "NOW" for "nurse collect" for Patient #83. At 0153 MD #9 ordered to suspend the insulin IV. An addendum was made to the History and Physical at approximately 0200 by MD #9 which revealed "...Unfortunately patient has been on insulin drip since 5pm without continuous fluid administration or repeat blood work, it is currently 2 am, Nursing staff was previously contacted requesting these, later on did let provider know there was difficulty obtaining blood work as well as delay in obtaining D51/2NS KCL fluid from pharmacy. Given we have no blood work, no fluids, for the safety of the patient will suspend insulin drip at this time, until blood work is back to ensure appropriateness of insulin drip infusion..." 0157 RN #10 documented the IV with D51/2NS KCL as started (2 hours and 27 minutes after ordered). At 0200 Patient #83's Insulin IV was suspended by RN #10. At 0256 Patient #83's Insulin IV was reordered and was resumed (56 minutes after it was stopped). On 11/29/2023 at 0514 Patient #83 was transported to a Stepdown Unit. Review of the ED record revealed no evidence that continuous telemetry monitoring or vital signs every 2 hours were initiated in the ED by a nurse, further the NOW Lactic Acid "nurse collect" order at 0127 was never drawn while the patient was in the ED. On the inpatient floor, at 0529, RN #11 cancelled the 0127 NOW Lactic Acid order "nurse collect" from the ED and reordered the NOW Lactic Acid order "lab collect". The Glycosylated Hemoglobin NOW that was ordered 11/28/2023 at 1908 resulted on 11/29/2023 at 0743 (12 hours and 35 minutes after ordered) with result of 12.3 (normal high range 6.3). At 0844 the Lactic Acid was drawn (3 hours and 15 minutes after it was ordered), was in the lab for processing at 0907, and resulted at 1108 (5 hours and 39 minutes after ordered) as "7.48" (high normal for lactic acid was 2.1). The computer system automatically reordered an additional Lactic Acid order by default and was collected at 1119 and was in the lab to be processed at 1148. At 1146 RN #12 documented a blood pressure of 141/67 with respirations of 36. At 1158 Rapid Response was called for Patient #83. At 1206 blood pressure was 65/40. At 1213 blood pressure was recorded at 68/40. At 1225 a Levophed (medication used to increase blood pressure) IV infusion was initiated via interosseous to increase her blood pressure. At 1245 the blood pressure was 126/84 at 98 percent oxygen saturation while the patient was being mechanically bagged at the bedside. At 1247 Patient #83 was intubated (mechanical ventilation), at 1250 Patient #83 was transferred to the medical intensive care unit. At 1256 the second Lactic Acid resulted as critically high "11.96". After discussion with the family, Hospitalist MD #16 changed Patient #83 Full Resuscitation status to Limited Resuscitation with no cardiopulmonary resuscitation (CPR). Patient #83 expired on 11/30/2023 at 1337.

Review on 12/06/2023 of a Patient Safety Analysis (Incident Report) completed by RN #12 on 12/01/2023 at 1917 revealed this Care Event was a "Delay in Care" and the issue was "Lack of timely response to Order", for Patient #83. A description "A NOW LA (lactic acid) order was placed at 0529. Lab wasn't drawn until 0844, and in lab at 0907. Critical results of lactic acid 7.48 reported at 1108. MD at 1114...Shortly after this (within the hour), the patient took a turn and had to be intubated at bedside and sent to ICU (intensive care unit) ...Solution to Prevent this from Recurring? Promptly follow orders..." This Patient Safety Report was still in process. Review of the report revealed Patient #83 had a delay in lab work.

Request to interview MD #9 revealed she was unavailable for interview.

Request to interview MD #16 revealed he was unavailable for interview.

Telephone interview on 12/07/2023 at 1632 with RN #10 who cared for Patient #83 in the Orange Pod (location in the ED for pending admissions) revealed "...I work on an inpatient unit and was pulled to the ED that day. It's a revolving door, I don't recall this patient in particular. If I can't get the labs, I would call a phlebotomist after 3 tries to get the labs if I couldn't..." Interview revealed she could not remember why the NOW lactic acid order was not collected. Interview revealed physician orders for Patient #83 were not followed.

Interview on 12/08/2023 at 0915 with RN #11 revealed she did remember Patient #83 and worked night shift. "...I did not receive a report on this patient from the ED. You have to look up the medical record number and sometimes the charge nurse gets an alert that the patient is coming and will print the face sheet. I had to piece it together and go through the orders. I reordered the lab work when I saw it was pending. My concern is we have had trouble getting in contact with the phlebotomist. That morning they were not logged into to their imobile device. I called the general lab number, and no one answered. I then contacted my house supervisor, and he told me 'we don't have another option right now.' I can't recall if she was on a telemetry box or not, I was only with her over an hour..." Interview revealed not being able to reach a phlebotomist during night shift had happened before. Interview revealed RN #11 had called multiple times to reach the lab phlebotomist to draw NOW blood orders without reaching someone. Interview revealed lab Turn Around Time for NOW lab orders was not followed for Patient #83.

Interview on 12/08/2023 at 1309 with Laboratory Phlebotomist Supervisor #17 revealed "...the phlebotomists do not collect in the ED; we will help if called. All labs ordered in the ED default to "nurse collect". The expectation was for STAT and NOW orders to be from order to collection in 15 minutes and to be resulted in an hour from order..." Interview revealed lab collection for STAT and NOW orders for Patient #83 did not follow hospital policy for lab turnaround times.

Interview on 12/08/2023 at 1414 with NP #6 revealed her expectation for Patient #83, was for her to have continuous ECG monitoring and vital signs every 2 hours while in the ED. Interview revealed physician orders were not followed for Patient #83.

Interview on12/08/2023 at 1425 with RN #3 who cared for Patient #83 in the Hallway Bed 17 on 11/28/2023 revealed "...I remember her. It was an extremely busy day...she was a hard stick; I used an ultrasound to start her IV. The problem with hallway beds is they have no dedicated monitor. She had a monitor and vital signs ordered. I strongly advocated for her to get moved into a bed with the CNC (clinical nurse coordinator), and it didn't happen. She didn't think it was a big deal. We don't have the capability to link the patient to a monitor in a hallway bed. She wasn't on a monitor; I spent the afternoon telling the CNC and MD. The doctors don't have any say, it's up to the CNC where patients are roomed. I sat behind her all day, ...I was extremely frustrated..." Interview revealed Patient #83 was not placed on continuous ECG monitoring, nor were vital signs monitored every 2 hours. Interview revealed physician orders were not followed for Patient #83.

Interview on 12/08/2023 at 1230 with Nursing Vice President of ED Services, RN #20 revealed she could not explain the lack of telemetry monitoring or vital signs for Patient #83 while in the ED. Interview revealed the ED nurse should elevate to the ED Charge Nurse for the need to continuously monitor a patient in a hallway bed if one was not available. Further interview revealed the ED Provider and ED Nurse were responsible for monitoring lab results via electronic medical record in the ED. Interview revealed hospital policy was not followed for Patient #83.

Interview on 12/09/2023 at 1159 with Lab Director #18 revealed "...I do know we had a call out that day. The lactic acid was available for the lab tech to see at 1016 but wasn't called to the floor until 1108. I don't know what the delay was. The expectation was to call as soon as the result was available. The expectation for lab collection and processing was to follow the policy guidelines, and for STAT and NOW results to be completed within an hour..." Interview revealed lab collection and processing did not follow hospital policy for Patient #83.

Patient #83 was presented to the ED with dizziness on 11/28/2023 at 1216. The patient had STAT (immediate) lab work ordered at 1218 with continuous ECG monitoring. Labs were drawn at 1358 (1 hour and 40 minutes after ordered). Labs arrived at the lab at 1412 and resulted at 1532 (3 hours and 14 minutes after ordered). The blood glucose was 1137 (critically high). Insulin IV infusion was ordered at 1626 and initiated at 1709 (1 hour and 13 minutes after ordered and 1 hour and 37 minutes after the glucose resulted). Orders for continuous ECG monitoring placed at 1218, and vital signs every 2 hours were never initiated in the ED. At 2349 an IV infusion of D51/2 KCL was ordered that was not completed until 0157 (2 hours. and 8 minutes after ordered). Lactic acid was ordered NOW at 0127 for nurse collect in the ED. At 0200 a physician wrote there was a delay in labs and fluids so stopped the insulin IV infusion. The lactic acid was not collected in the ED. At 0529 the original lactic acid NOW, order was cancelled and reordered as lab collect NOW on the floor. It was collected at 0844 (3 hours and 15 minutes after ordered at 0529) and resulted at 1108 (9 hours and 41 minutes after originally ordered at 0127) with a result of 7.48 critical high. A second lactic acid was reordered at 1108 and resulted at 1256 (1 hr. and 36 minutes after ordered) with a result of 11.96 critically high. A rapid response was called previously at 1158, the patient was intubated at 1247, and ultimately expired on 11/30/2023.

3. Review of the CIWA (Clinical Institute Withdrawal Assessment for Alcohol) /Alcohol Withdrawal Plan, effective date 07/20/2022 revealed "...Monitoring Phase ...Now ONCE, when plan is initiated with goal CIWA < (less than) 15..." The CIWA/Alcohol Withdrawal Plan Reference Information included 10 questions, questions 1-9 can score between 0 and 7 points each question, question 10, can score 0 to 4 points, depending on severity of symptoms for each question. Score range 0-68. Questions with observations: 1. Nausea/Vomiting? 2. Paroxysmal sweats? 3. Agitation? Headache, fullness in head? 5. Anxiety? 6. Tremor? 7. Visual disturbances? 8. Tactile disturbances? 9. Auditory disturbances? 10.Orientation and clouding of sensorium -Ask what day it is? "...CIWA Management Communication If CIWA > 15 for four consecutive hours, contact provider to initiate Severe Withdrawal Phase and/or to consider transfer to higher level of care..."

Closed medical record review on 11/16/2023 revealed Patient #43, a 39-year-old who presented to the emergency department (ED) by private vehicle on 08/14/2023 at 1603 with complaints of "...chest pain, nausea, clammy, lightheaded, and right-side tingling for several week. Drinks 12 beers a day...." At 1603 triage by Registered Nurse (RN) #21 with vital signs: temperature 98.5, heart rate 97, respirations 18, blood pressure141/89, oxygen saturation of 96 percent on room air, and pain of 4/10 (1 being least pain, and 10 being most pain) and was assigned an emergency severity index [ESI] (level 1 as the most urgent and 5 as the least urgent) of 2. Patient #43 was then moved to the ED waiting room IPA (Internal Processing Area) area and was seen by Nurse Practitioner (NP) #22. At 1650 initial labs, ekg, and chest Xray were completed, and Patient #43 was assigned to ED Medical Doctor (MD) #23. Review of the ER Physician Note from 08/14/2023 at 1727 by MD #23 revealed a review of lab, ekg and chest Xray results from 08/14/2023 did not show any critical results. At 1732 MD #23 ordered a GI cocktail (oral combination of medications given for indigestion), Zofran 4mg orally (medication given for nausea and vomiting). An addendum to MD #23's ER Report Note revealed "...On reassessment patient and his mom who is now accompanying him are updated on his results. He is still in the waiting room unfortunately. I have ordered IV (intravenous) fluids, CIWA protocol and 1mg of Ativan (a sedative given for anxiety and seizures) as he is slightly tremulous (shaking) and diaphoretic (sweating) my reassessment [sic]...Hospitalist has been consulted for admission..." At 1841 MD #23 placed orders for IV (intravenous) fluids-NS NOW, thiamine (dietary supplement/nutrient) 100 milligrams (mg) orally STAT (immediately), and CIWA scale/protocol (alcohol withdrawal plan/protocol). At 1851 vital signs were rechecked by IPA ED RN #24 temperature 98.3, heart rate of 103, blood pressure 132/82, and oxygen saturation of 92 percent on room air, the GI Cocktail, and Zofran were administered in the ED waiting room. At 1947 MD #23 ordered Ativan 1mg IV push NOW (urgent). Per the CIWA plan at 2100 a multivitamin orally was ordered and CIWA Scale assessment. The History and Physical was initiated on 08/14/2023 at 2229 by Hospitalist MD #25 while in the ED waiting room, and new orders were placed for aspirin orally NOW, Lopressor (medication given in treatment of alcohol withdrawal) 12.5 mg orally, and again IV access at 2226. At 2305 MD #25 ordered Patient #43 phenobarbital (medication given to prevent seizure) 60 mg orally three times a day STAT and a CIWA Scale reassessment was due to be completed per protocol. No nursing reassessments, medication administrations, IV access/fluids, or physician orders were completed after 1851 for Patient #43 while in the ED waiting room. On 08/15/2023 at 0057 Patient #43 was moved to the Red Pod (ED area for the most acute patients) room 11. At 0105 MD #25 ordered Patient #43 to have Ativan 4mg IV STAT and was given at 0106 by RN #27. Review of the ER Report Note on 08/15/2023 at 0107 by MD #26 revealed "...I became involved in the patient's care after he apparently left the waiting room where he was awaiting admission and then had a seizure and struck his head on the sidewalk outside of the ER (emergency room) entrance. On my evaluation, the patient seems postictal (the period following a seizure, disorienting symptoms, confusion, and drowsiness), he is not actively seizing. He does have a history of heavy alcohol use, drinks about 12 beers a daily. He has been in the emergency department waiting room for 9 hours and has not received any Ativan or Phenobarbital. I suspect that he seized due to alcohol withdrawal. Will obtain head CT (cat scan) given the patient did strike his head, he also has a small laceration that will require repair...." Record review revealed the ED waiting room orders for IV fluids NOW on 08/14/2023 at 1841 to 08/15/2023 at 0106 (5 hrs. and 25 min), Ativan IV NOW ordered on 08/14/2023 at 1947 to administered on 08/15/2023 at 0106 (5 hours 19 min), and Phenobarbital STAT ordered on 08/14/2023 at 2305 to administered on 08/15/2023 at 0150 (2 hours and 45 min) for Patient #43 were delayed and no CIWA score/assessment was completed until 08/15/2023 at 0437 (9 hours and 56 minutes after ordered). No CIWA score/assessment was documented before the patient had a seizure event with sustained head injury. There was no nursing reassessment, or nursing care after 08/14/2023 at 1851 by RN #22 until 08/15/2023 at 0057 (6 hours and 1 minute). Patient #43 was admitted to an inpatient room on 08/15/2023 at 0334 from the ED. Patient #43 was discharged home on 08/17/2023.

Review of the Patient Care Analysis (Incident) report submitted by MD #25 on 08/15/2023 at 0443 revealed the date of event was 08/15/2023 at 0000. Brief description revealed "...patient was in waiting room for 9 hours, did not receive any medications for alcohol withdrawal, then had a seizure and sustained a head injury..." Investigator #28 Notes revealed: We continue to work through ways to provide care to patients in the waiting room during peak times of surge and limited staffing..." Further comments were reviewed by the hospital Pharmacy, dated 11/17/2023 (3 months after the event) that revealed "...Suggest education to send out of CIWA precautions...Nurse could have clarified with provider about the CIWA order and administered medication..." Level of Harm was documented as "Harm-required intervention" and Primary Action to Prevent Recurrence: "Increase in Staffing/Decrease in Workload."

MD #23 declined to be interviewed.

Interview on 11/15/2023 at 1414 with MD #26 revealed "...With the current process it's still difficult to treat patients in the ED waiting room. The goal was for delays in care to not happen, but especially at night it occurs. I have concerns with delays in patient care. The patient was better off in a more clinical area where they can be monitored ..." Interview revealed MD #26 had concerns for patient safety in the ED waiting