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Based on observation, interview, and record review, the facility failed to ensure:

1. Patients were discharged in stable or improved condition when 3 patients (Patients 32, 29, and 16) did not have reassessments prior to discharge, resulting in the potential for unstable patients to be discharged or patients to deteriorate after discharge from the ED;

2. Emergency Department (ED) nurses were trained, and a new policy was made available to them, when they changed from a three level acuity system to a five level emergency severity index (ESI) system, resulting in lack of knowledge and lack of a reference for the triage nurses assigning ESI levels and determining the priority in which patients would be seen. This had the potential to result in a delay in necessary emergency care, harm, or death (A1104);

3. ED nurses triaged patients in accordance with the nationally recognized ESI standards, including consideration of both subjective and objective assessment information, resulting in the potential for delays in care, harm, or death (A1104);

4. The triage policy included time frames for reassessment of patients who were placed in the lobby to wait for medical evaluation and treatment, possibly resulting in deterioration in the condition of one patient (Patient 27) and the potential for deterioration in other patient's conditions, harm, or death (A1104);

5. The Emergency Department (ED) nursing staffing plan included adequate staff for the triage/fast track area (RME) where patients received a secondary triage assessment and where multiple patients moved in and out for treatment on a continuous and rotating basis, resulting in incomplete/inaccurate medical records due to the volume of records the staff were responsible for at one time, failure to perform reassessments on one patient (Patient 27) who had a stroke while waiting in the lobby, and the potential for harm or death in patients who were waiting for a secondary triage, reassessment, or treatments/procedures to be performed with no staff assigned to them (A1112); and

6. Adequate numbers of nursing personnel (Registered Nurses [RNs] and Emergency Room Technicians [ERTs]) were present in the ED to meet the anticipated needs of their patients as identified in their staffing plan, resulting in the potential for patient harm or death (A1112).

The cumulative effect of these systemic problems resulted in failure of the facility to provide emergency services in a safe and effective manner.

Findings:

1a. Patient 32, a 2 year old male, was taken to the ED by his parents on March 14, 2015, at 1:33 a.m., with complaints of diarrhea for five days, and fever since that afternoon. The triage note, completed at 2:06 a.m., indicated the child had a temperature of 102.4 degrees Fahrenheit (in the danger zone according to the ESI guidelines) and a heart rate of 147 (normal 80-110).

The record indicated the physician evaluated Patient 32 and diagnosed him with diarrhea and fever. The patient was given Tylenol and Motrin while he was in the ED, and discharged home at 3:36 a.m. with a prescription for zofran (for nausea), and instructions for taking Tylenol and Motrin. There was no evidence the patient's temperature was taken prior to discharge. The last temperature in the record was 102.4 degrees Fahrenheit.

b. Patient 32 was taken back to the ED by his parents on March 15, 2015, at 2:24 a.m. (25 hours later), with complaints that his fever was not better. The triage note, completed at 2:27 a.m., indicated the child had a temperature of 102.9 (in the danger zone according to the ESI guidelines) and a heart rate of 144 (normal 80-110).

The record indicated the physician evaluated Patient 32 and diagnosed him with viral syndrome, ear infection, and sinus infection, with a note "there is no fever at this point in time." The patient was discharged home with a prescription for an antibiotic, Tylenol, and Motrin. There was no evidence the fever was treated in the ED. There was no evidence the temperature was retaken. The last documented temperature was 102.9 degrees Fahrenheit.

c. Patient 29, a 65 year old female, presented to the ED on March 21, 2015, at 52 minutes after midnight, with complaints of an asthma attack with shortness of breath, wheezing, and productive cough. The triage note, completed at 54 minutes after midnight, indicated the patient had a blood pressure of 178/110 (normal 120/80).

The ED assessment indicated the patient had expiratory wheezes throughout all lung fields, and received a breathing treatment (which can increase the blood pressure) and steroids for her symptoms.

The record indicated Patient 29 was discharged home with prescriptions for her asthma. There was no evidence in the record her blood pressure was reviewed by the physician. There was no evidence her blood pressure was taken after the initial one in triage (although heart rate, respiratory rate, and oxygenation level were taken). There was no evidence Patient 29 had a safe blood pressure on discharge from the ED.



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d. On March 24, 2015, the record for Patient 16 was reviewed. Patient 16, a 15 month old child, presented to the facility ED on March 20, 2015, at 2:06 a.m., with the chief complaint of fever.

Patient 16's temporal temperature was 99.7° Fahrenheit (F) on March 20, 2015, at 2:07 a.m.

Patient 16 was "Triaged" at 2:42 a.m.; vital signs were taken at 2:45 a.m., to include a heart rate of 124 beats per minute, respiratory rate of 26 per minute, and a rectal temperature of 99.8°F; and an Emergency Severity Index (ESI) of 4 (less urgent).

The "Physician Documentation/Notes" dated March 20, 2015, indicated Patient 16 was seen by a physician at 3:28 a.m., and "Temperature is 103.9 Fahrenheit" with a review of systems to include "fever ... ear pain, ear pulling ... cough," and a physical examination which included "injected right TM (tympanic membrane - ear infection)."

Patient 16 was discharged home on March 20, 2015, at 3:59 a.m., with a prescription for antibiotics and instructions to see private physician in one to two days.

There was no indication Patient 16's temperature was taken after being documented by the physician as 103.9°F, at 3:28 a.m.

There was no indication Patient 16's vital signs were taken prior to discharge from the facility ED.

During an interview with Registered Nurse (RN) 2, on March 25, 2015, at 1:35 p.m., she reviewed the record and was unable to find documentation of Patient 16's temperature after the physician's documented temperature of 103.9°F at 3:28 a.m. RN 2 stated she was unable to determine from the record if the physician's documented temperature for Patient 16 was correct. In addition, RN 2 stated she would have assessed Patient 16 prior to discharge which would have included a discharge temperature.

Based on observation, interview, and record review, the facility failed to ensure;

1. The Emergency Department (ED) nursing staffing plan included adequate staff for the triage/fast track area (RME) where patients received a secondary triage assessment and where multiple patients moved in and out for treatment on a continuous and rotating basis; and

2. Adequate numbers of nursing personnel (Registered Nurses [RNs] and Emergency Room Technicians [ERTs]) were present in the ED to meet the anticipated needs of their patients as identified in their staffing plan.

These failed practices resulted in incomplete/inaccurate medical records due to the volume of records the staff were responsible for at one time, failure to perform reassessments on one patient (Patient 27) who had a stroke while waiting in the lobby, and the potential for harm or death in patients who were waiting for a secondary triage, reassessment, or treatments/procedures to be performed with no staff assigned to them.

Findings:

1. During a tour of the ED on March 23, 2015, at 9:50 a.m., accompanied by the Director Emergency Department (DED), an ED RN was observed in the front entrance area of the ED lobby next to the registration window with a vital signs machine.

The DED stated the RN in the front area was known as the, "pivot" nurse. The DED stated the "pivot" nurse assigned an ESI level to patients on arrival, the level one and two patients would go straight back to a bed, and the level three, four, and five patients would be directed to the lobby to wait for a different nurse (a triage nurse) to call them in. The director stated the triage nurse would complete a "focus" assessment on the patient.

During the observation, two patients (at separate times) approached the nurse asking to be seen in the ED. The RN asked the patients what they were there for and if they had ever been there before, and took a set of vital signs. There were no other questions asked.

For the first patient, the RN called the charge nurse to get an immediate bed based on the information she had gathered.

For the second patient, the RN told the patient to have a seat in the lobby based on the information she had gathered.

Upon entering the triage area, there was one RN present with one provider assigned to the area. The DED explained the area acted as a "combination" (secondary) triage/rapid medical screening exam/fast track (RME) area. The room contained multiple chairs with multiple patients sitting in them. The DED stated the patients were all in various stages of triage, examination, and/or treatment.

The facility policy titled "Nurse Staffing Plan" was reviewed on March 23, 2015. The policy indicated the ED staffing would include one charge nurse and six RNs 24 hours a day, with four RNs for "mid shift overlap."

A review of the ED daily staffing assignment template indicated the overlap shifts included one RN at 10 a.m., two RNs at 12 noon, and one RN at 3 p.m.

During an interview with the DED on March 24, 2015, at 9 a.m., he stated when every shift was filled, the morning staffing (one charge nurse and six RNs) would cover one nurse in charge, four nurses for the 16 ED beds, one pivot nurse, and one triage nurse. He stated the 10 a.m. nurse would be assigned as a second triage nurse, the 12 noon nurses would provide lunch coverage for other staff, and the 3 p.m. nurse would assist in triage/RME. According to the DED, when all shifts were covered, the triage/RME area would have one RN at 7 a.m., two RNs at 10 a.m., and three RNs at 3 p.m.

During a concurrent interview with RN 1 and RN 2 on March 24, 2015, at 2 p.m., the RNs explained after level three, four, and five patients were sent to the lobby by the pivot nurse, the role of the triage nurse was to call them in and complete a "focus" assessment, then send them back to the lobby. The nurses explained the patients would then go "back and forth" between the RME room and the lobby, receiving their examination by the provider, having tests done, receiving treatments, and eventually being discharged or sent to a bed in the ED if necessary.

RN 2 stated the nurses assigned to triage were doing secondary triage on some patients, and assisting with treatments and procedures on other patients, within the same period of time. RN 2 stated there was "no physical way" they could keep up on charting on all of the patients being seen and treated in that area. RN 2 stated there were currently 43 patients "on the board" (in some stage of treatment in the ED). RN 2 stated with 16 ED beds, that left 27 patients in the process of treatment in the RME area (many of who were located in the lobby), with two or three nurses assigned there. She stated there was not enough staff to assign patients to nurses to manage their care/flow, so it was very difficult to keep up with what was being done on what patients, what was pending on what patients, what had been ordered on what patients, and what patients were waiting for dispositions.

2. The facility policy titled "Nurse Staffing Plan" was reviewed on March 23, 2015. The policy indicated nursing care was delivered in a modified team approach, and was provided by RNs and ERTs.

A review of the ED daily staffing assignment template indicated the following staff was needed to meet the anticipated needs of the patients:

7a - 7p: One charge RN, six RNs, two ERTs;
9a - 9p: Two ERTs;
10a - 10p: One RN;
12 noon - 12 midnight: Three RNs and one ERT;
3p - 3a: One RN and one ERT; and
7p - 7a: One charge RN, six RNs, and two ERTs.

A review of the actual staffing for the week of March 16 through 22, 2015, indicated the following:

a. Monday, March 16, 2015:

- short one 7a-7p RN, assigned an RN to RME area, and an ERT to the pivot (ESI level) assignment (an assignment that requires an RN for assessment and acuity level);
- short one 9a-9p ERT;
- short one 12p-12a RN;
- short the 3p-3a RN; and
- short one 7p-7a ERT.

b. Tuesday, March 17, 2015:

- short one 7a-7p RN, assigned an RN to triage area, and an ERT to the pivot (ESI level) assignment;
- short one 9a-9p ERT;
- short one 12p-12a RN;
- short the 3p-3a RN; and
- short both 7p-7a ERTs.

c. Wednesday, March 18, 2015:

- short one 7a-7p RN and one 7a-7p ERT;
- short one 12p-12a RN;
- short the 3p-3a RN; and
- short one 7p-7a ERT.

d. Thursday, March 19, 2015:

- short two 7a-7p RNs and one 7a-7p ERT;
- short one 9a-9p ERT; and
- short one 7p-7a ERT.

e. Friday, March 20, 2015:

- short one 7a-7p RN;
- short one 9a-9p ERT;
- short one 12p-12a RN; and
- short one 7p-7a RN.

f. Saturday, March 21, 2015:

- short one 9a-9p ERT;
- short two 12p-12a RNs; and
- short the 3p-3a RN and the 3p-3a ERT.

g. Sunday, March 22, 2015:

- short two 7a-7p RNs;
- short two 12p-12a RNs;
- short the 3p-3a RN and the 3p-3a ERT; and
- short one 7p-7a RN and both 7p-7a ERTs.

At 3 p.m. on March 22, 2015, the ED was short by five RNs.

During an interview with the DED on March 24, 2015, at 9 a.m., the DED stated he was aware of the staffing problems in the ED, but he had employees out on leave, and he was "doing the best I can."


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Based on observation, interview, and record review, the facility failed to ensure:

1. Patients were discharged in stable or improved condition when 3 patients (Patients 32, 29, and 16) did not have reassessments prior to discharge, resulting in the potential for unstable patients to be discharged or patients to deteriorate after discharge from the ED;

2. Emergency Department (ED) nurses were trained, and a new policy was made available to them, when they changed from a three level acuity system to a five level emergency severity index (ESI) system, resulting in lack of knowledge and lack of a reference for the triage nurses assigning ESI levels and determining the priority in which patients would be seen. This had the potential to result in a delay in necessary emergency care, harm, or death (A1104);

3. ED nurses triaged patients in accordance with the nationally recognized ESI standards, including consideration of both subjective and objective assessment information, resulting in the potential for delays in care, harm, or death (A1104);

4. The triage policy included time frames for reassessment of patients who were placed in the lobby to wait for medical evaluation and treatment, possibly resulting in deterioration in the condition of one patient (Patient 27) and the potential for deterioration in other patient's conditions, harm, or death (A1104);

5. The Emergency Department (ED) nursing staffing plan included adequate staff for the triage/fast track area (RME) where patients received a secondary triage assessment and where multiple patients moved in and out for treatment on a continuous and rotating basis, resulting in incomplete/inaccurate medical records due to the volume of records the staff were responsible for at one time, failure to perform reassessments on one patient (Patient 27) who had a stroke while waiting in the lobby, and the potential for harm or death in patients who were waiting for a secondary triage, reassessment, or treatments/procedures to be performed with no staff assigned to them (A1112); and

6. Adequate numbers of nursing personnel (Registered Nurses [RNs] and Emergency Room Technicians [ERTs]) were present in the ED to meet the anticipated needs of their patients as identified in their staffing plan, resulting in the potential for patient harm or death (A1112).

The cumulative effect of these systemic problems resulted in failure of the facility to provide emergency services in a safe and effective manner.

Findings:

1a. Patient 32, a 2 year old male, was taken to the ED by his parents on March 14, 2015, at 1:33 a.m., with complaints of diarrhea for five days, and fever since that afternoon. The triage note, completed at 2:06 a.m., indicated the child had a temperature of 102.4 degrees Fahrenheit (in the danger zone according to the ESI guidelines) and a heart rate of 147 (normal 80-110).

The record indicated the physician evaluated Patient 32 and diagnosed him with diarrhea and fever. The patient was given Tylenol and Motrin while he was in the ED, and discharged home at 3:36 a.m. with a prescription for zofran (for nausea), and instructions for taking Tylenol and Motrin. There was no evidence the patient's temperature was taken prior to discharge. The last temperature in the record was 102.4 degrees Fahrenheit.

b. Patient 32 was taken back to the ED by his parents on March 15, 2015, at 2:24 a.m. (25 hours later), with complaints that his fever was not better. The triage note, completed at 2:27 a.m., indicated the child had a temperature of 102.9 (in the danger zone according to the ESI guidelines) and a heart rate of 144 (normal 80-110).

The record indicated the physician evaluated Patient 32 and diagnosed him with viral syndrome, ear infection, and sinus infection, with a note "there is no fever at this point in time." The patient was discharged home with a prescription for an antibiotic, Tylenol, and Motrin. There was no evidence the fever was treated in the ED. There was no evidence the temperature was retaken. The last documented temperature was 102.9 degrees Fahrenheit.

c. Patient 29, a 65 year old female, presented to the ED on March 21, 2015, at 52 minutes after midnight, with complaints of an asthma attack with shortness of breath, wheezing, and productive cough. The triage note, completed at 54 minutes after midnight, indicated the patient had a blood pressure of 178/110 (normal 120/80).

The ED assessment indicated the patient had expiratory wheezes throughout all lung fields, and received a breathing treatment (which can increase the blood pressure) and steroids for her symptoms.

The record indicated Patient 29 was discharged home with prescriptions for her asthma. There was no evidence in the record her blood pressure was reviewed by the physician. There was no evidence her blood pressure was taken after the initial one in triage (although heart rate, respiratory rate, and oxygenation level were taken). There was no evidence Patient 29 had a safe blood pressure on discharge from the ED.



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d. On March 24, 2015, the record for Patient 16 was reviewed. Patient 16, a 15 month old child, presented to the facility ED on March 20, 2015, at 2:06 a.m., with the chief complaint of fever.

Patient 16's temporal temperature was 99.7° Fahrenheit (F) on March 20, 2015, at 2:07 a.m.

Patient 16 was "Triaged" at 2:42 a.m.; vital signs were taken at 2:45 a.m., to include a heart rate of 124 beats per minute, respiratory rate of 26 per minute, and a rectal temperature of 99.8°F; and an Emergency Severity Index (ESI) of 4 (less urgent).

The "Physician Documentation/Notes" dated March 20, 2015, indicated Patient 16 was seen by a physician at 3:28 a.m., and "Temperature is 103.9 Fahrenheit" with a review of systems to include "fever ... ear pain, ear pulling ... cough," and a physical examination which included "injected right TM (tympanic membrane - ear infection)."

Patient 16 was discharged home on March 20, 2015, at 3:59 a.m., with a prescription for antibiotics and instructions to see private physician in one to two days.

There was no indication Patient 16's temperature was taken after being documented by the physician as 103.9°F, at 3:28 a.m.

There was no indication Patient 16's vital signs were taken prior to discharge from the facility ED.

During an interview with Registered Nurse (RN) 2, on March 25, 2015, at 1:35 p.m., she reviewed the record and was unable to find documentation of Patient 16's temperature after the physician's documented temperature of 103.9°F at 3:28 a.m. RN 2 stated she was unable to determine from the record if the physician's documented temperature for Patient 16 was correct. In addition, RN 2 stated she would have assessed Patient 16 prior to discharge which would have included a discharge temperature.

Based on observation, interview, and record review, the facility failed to ensure;

1. The Emergency Department (ED) nursing staffing plan included adequate staff for the triage/fast track area (RME) where patients received a secondary triage assessment and where multiple patients moved in and out for treatment on a continuous and rotating basis; and

2. Adequate numbers of nursing personnel (Registered Nurses [RNs] and Emergency Room Technicians [ERTs]) were present in the ED to meet the anticipated needs of their patients as identified in their staffing plan.

These failed practices resulted in incomplete/inaccurate medical records due to the volume of records the staff were responsible for at one time, failure to perform reassessments on one patient (Patient 27) who had a stroke while waiting in the lobby, and the potential for harm or death in patients who were waiting for a secondary triage, reassessment, or treatments/procedures to be performed with no staff assigned to them.

Findings:

1. During a tour of the ED on March 23, 2015, at 9:50 a.m., accompanied by the Director Emergency Department (DED), an ED RN was observed in the front entrance area of the ED lobby next to the registration window with a vital signs machine.

The DED stated the RN in the front area was known as the, "pivot" nurse. The DED stated the "pivot" nurse assigned an ESI level to patients on arrival, the level one and two patients would go straight back to a bed, and the level three, four, and five patients would be directed to the lobby to wait for a different nurse (a triage nurse) to call them in. The director stated the triage nurse would complete a "focus" assessment on the patient.

During the observation, two patients (at separate times) approached the nurse asking to be seen in the ED. The RN asked the patients what they were there for and if they had ever been there before, and took a set of vital signs. There were no other questions asked.

For the first patient, the RN called the charge nurse to get an immediate bed based on the information she had gathered.

For the second patient, the RN told the patient to have a seat in the lobby based on the information she had gathered.

Upon entering the triage area, there was one RN present with one provider assigned to the area. The DED explained the area acted as a "combination" (secondary) triage/rapid medical screening exam/fast track (RME) area. The room contained multiple chairs with multiple patients sitting in them. The DED stated the patients were all in various stages of triage, examination, and/or treatment.

The facility policy titled "Nurse Staffing Plan" was reviewed on March 23, 2015. The policy indicated the ED staffing would include one charge nurse and six RNs 24 hours a day, with four RNs for "mid shift overlap."

A review of the ED daily staffing assignment template indicated the overlap shifts included one RN at 10 a.m., two RNs at 12 noon, and one RN at 3 p.m.

During an interview with the DED on March 24, 2015, at 9 a.m., he stated when every shift was filled, the morning staffing (one charge nurse and six RNs) would cover one nurse in charge, four nurses for the 16 ED beds, one pivot nurse, and one triage nurse. He stated the 10 a.m. nurse would be assigned as a second triage nurse, the 12 noon nurses would provide lunch coverage for other staff, and the 3 p.m. nurse would assist in triage/RME. According to the DED, when all shifts were covered, the triage/RME area would have one RN at 7 a.m., two RNs at 10 a.m., and three RNs at 3 p.m.

During a concurrent interview with RN 1 and RN 2 on March 24, 2015, at 2 p.m., the RNs explained after level three, four, and five patients were sent to the lobby by the pivot nurse, the role of the triage nurse was to call them in and complete a "focus" assessment, then send them back to the lobby. The nurses explained the patients would then go "back and forth" between the RME room and the lobby, receiving their examination by the provider, having tests done, receiving treatments, and eventually being discharged or sent to a bed in the ED if necessary.

RN 2 stated the nurses assigned to triage were doing secondary triage on some patients, and assisting with treatments and procedures on other patients, within the same period of time. RN 2 stated there was "no physical way" they could keep up on charting on all of the patients being seen and treated in that area. RN 2 stated there were currently 43 patients "on the board" (in some stage of treatment in the ED). RN 2 stated with 16 ED beds, that left 27 patients in the process of treatment in the RME area (many of who were located in the lobby), with two or three nurses assigned there. She stated there was not enough staff to assign patients to nurses to manage their care/flow, so it was very difficult to keep up with what was being done on what patients, what was pending on what patients, what had been ordered on what patients, and what patients were waiting for dispositions.

2. The facility policy titled "Nurse Staffing Plan" was reviewed on March 23, 2015. The policy indicated nursing care was delivered in a modified team approach, and was provided by RNs and ERTs.

A review of the ED daily staffing assignment template indicated the following staff was needed to meet the anticipated needs of the patients:

7a - 7p: One charge RN, six RNs, two ERTs;
9a - 9p: Two ERTs;
10a - 10p: One RN;
12 noon - 12 midnight: Three RNs and one ERT;
3p - 3a: One RN and one ERT; and
7p - 7a: One charge RN, six RNs, and two ERTs.

A review of the actual staffing for the week of March 16 through 22, 2015, indicated the following:

a. Monday, March 16, 2015:

- short one 7a-7p RN, assigned an RN to RME area, and an ERT to the pivot (ESI level) assignment (an assignment that requires an RN for assessment and acuity level);
- short one 9a-9p ERT;
- short one 12p-12a RN;
- short the 3p-3a RN; and
- short one 7p-7a ERT.

b. Tuesday, March 17, 2015:

- short one 7a-7p RN, assigned an RN to triage area, and an ERT to the pivot (ESI level) assignment;
- short one 9a-9p ERT;
- short one 12p-12a RN;
- short the 3p-3a RN; and
- short both 7p-7a ERTs.

c. Wednesday, March 18, 2015:

- short one 7a-7p RN and one 7a-7p ERT;
- short one 12p-12a RN;
- short the 3p-3a RN; and
- short one 7p-7a ERT.

d. Thursday, March 19, 2015:

- short two 7a-7p RNs and one 7a-7p ERT;
- short one 9a-9p ERT; and
- short one 7p-7a ERT.

e. Friday, March 20, 2015:

- short one 7a-7p RN;
- short one 9a-9p ERT;
- short one 12p-12a RN; and
- short one 7p-7a RN.

f. Saturday, March 21, 2015:

- short one 9a-9p ERT;
- short two 12p-12a RNs; and
- short the 3p-3a RN and the 3p-3a ERT.

g. Sunday, March 22, 2015:

- short two 7a-7p RNs;
- short two 12p-12a RNs;
- short the 3p-3a RN and the 3p-3a ERT; and
- short one 7p-7a RN and both 7p-7a ERTs.

At 3 p.m. on March 22, 2015, the ED was short by five RNs.

During an interview with the DED on March 24, 2015, at 9 a.m., the DED stated he was aware of the staffing problems in the ED, but he had employees out on leave, and he was "doing the best I can."


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