HospitalInspections.org

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31688

Based on interview and record review, the facility:

1. Failed to ensure data was collected, measured, analyzed, and tracked to monitor Radiology discrepancies between the Emergency Department (ED) physician or teleradiologist, and the facility radiologist to determine whether follow-up care was necessary and appropriate actions were taken. (Refer to A273);

2. Failed to ensure data was collected, measured, analyzed, and tracked to monitor urine and wound culture/sensitivity results that were done in the ED and determined to be positive after the patient was discharged home to determine whether follow-up care was necessary and appropriate actions were taken. (Refer to A273); and

3. Leadership failed to ensure the Ongoing Professional Practice Evaluation (OPPE) profiles were completed and/or reviewed by the Department Chair or the Chief of Staff per facility policy and procedure. (Refer to A309).

The cumulative effect of these systemic problems resulted in the facility's failure to ensure patients were receiving quality care in a safe and effective manner.

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31688

Based on interview and record review, the facility failed to ensure data was collected, measured, analyzed, and tracked to monitor:

1. Radiology discrepancies (differences) between the Emergency Department (ED) physician or teleradiologist (radiologist who reads studies on-line), and the facility radiologist were not reviewed to determine whether follow-up care was necessary and appropriate action was taken; and,

2. Urine and wound cultures/sensitivities (determination of bacteria present and effective antibiotic(s)) that were done in the ED and determined to be positive after the patient was discharged home were not reviewed to determine whether follow-up care was necessary and appropriate action was taken.

This resulted in missed opportunities to identify processes for improvement, and the potential for unsafe practices to go unnoticed.

Findings:

1. During an interview with the Interim Director of the Emergency Department (IDED) on May 11, 2015, at 9 a.m., the IDED stated an on-line teleradiology group read the after hours x-rays (done after 7 p.m.). The director stated she did not know if the group read all x-rays or just the Computed Tomography (CT), Ultrasound (US), and Magnetic Resonance Imaging (MRI) studies. She stated the facility radiologist re-read x-rays the next day, but she did not know if all of the radiology procedures were re-read (those read by the teleradiology physician, those read by the ED physician, or both).

According to the IDED, if there was a discrepancy between the original x-ray interpretation and the interpretation done by the facility radiologist, the facility radiologist would identify it, but she was, "not sure," what the process was for communicating and resolving x-ray discrepancies.

During a tour of the Radiology Department on May 11, 2015, at 9:25 a.m., accompanied by the Chief Radiology Technologist (CRT) and the Director of Imaging Services (DIS), the CRT stated the ED physicians read all plain films (x-rays) after 7 p.m. on weekdays and after 6 p.m. on weekends. The CRT stated all CT, US, and MRI studies were read by a teleradiologist during those hours.

According to the CRT, all after hours x-rays and radiology studies were re-read the following day by the facility radiologist. The CRT stated ED physicians were required to put their interpretation of the x-ray into the radiology computer system, and teleradiology physicians were required to scan their interpretation into the computer system, so the facility radiologist would be able to see if he/she agreed with the interpretation during the re-read. The CRT stated if the facility radiologist's interpretation was different than that of the ED physician or the teleradiologist, a discrepancy would be logged in the radiology computer system on the, "discrepancy log."

A review of the discrepancy log on May 11, 2015, indicated hundreds of discrepancies were logged by the facility radiologists, with no evidence they were seen, reviewed, or acted on by the ED providers.

The DIS stated if an ED physician failed to enter an interpretation of the x-ray into the radiology system, the radiologist would enter that as a discrepancy on the log. According to the DIS, many or all of the logged discrepancies could have been entered as a result of the ED physician failing to enter an interpretation, and may not reflect a positive finding or actual discrepancy. The CRT stated if the discrepancy was addressed by the ED provider, there was no mechanism for the provider to indicate that on the log, and the discrepancy would not drop off of the log.

According to the CRT, there was no way to know if any or all of the discrepancies had been addressed. The CRT and the DIS stated they did not monitor the contents of the log, compliance with addressing the discrepancies on the log, or whether there were trends developing that could identify opportunities for improvement (common physician, common test, common time). The CRT and the DIS stated monitoring of the process was not their responsibility, it was the responsibility of the ED.

During an interview with Radiologist 1 on May 11, 2015, at 9:40 a.m., the radiologist stated if he saw a discrepancy in the after hours reading of an x-ray or radiology study, he would enter it onto the discrepancy log. He stated if the discrepancy was, "significant," he would call the ED and speak to the provider about it in addition to entering it onto the log.

According to the radiologist, there was not always an interpretation entered into the system by the ED physician, so he had no way of knowing what the ED physician diagnosed the patient with or treated the patient for. The radiologist stated he attended the radiology medical staff committee meetings, and he did not recall any discussions of the radiology discrepancy process. He stated he did not know if the process was being monitored for contents of the log, compliance with addressing the discrepancies on the log, or whether there were trends developing that could identify opportunities for improvement (common physician, common test, common time).

A review of the contents of the discrepancy log on May 11, 2015, indicated the following:

a. 11 of 11 after hours x-rays ordered by the ED physicians, and completed during the time the ED physicians were required to read them, did not have an initial interpretation documented in the radiology system. There was no mechanism for the facility radiologist to know what the ED physician diagnosed the patient with or treated the patient for.

All 11 interpretations by the facility radiologist were entered onto the discrepancy log in the absence of an initial interpretation by the ED physician. There was no evidence an ED provider reviewed the discrepancies to determine whether the ED physician diagnosed and treated the patients correctly;

b. Patient 9, an 8 year old male, presented to the ED on May 4, 2015, with complaints of fever with shortness of breath and nausea. A CT of the abdomen and pelvis was ordered by the ED physician and the initial interpretation was completed by the teleradiology physician at 6:20 a.m.

The initial interpretation included right lower lobe infiltrates (pneumonia), splenomegaly (enlarged spleen), a normal appendix, and mesenteric adenitis (inflammation of the lymph nodes in the right side of the abdomen).

A radiology discrepancy report dictated at 8:31 a.m., indicated, in addition to the above findings, the facility radiologist saw a masslike density in the right lower lobe of the lung as well as borderline enlargement of the appendix. The radiologist recommended the patient receive follow-up for both of these findings.

There was no indication on the log the discrepancy was ever seen, reviewed, or followed up on by the ED provider.

A review of the record for Patient 9 indicated no documentation was present regarding the recommendations made by the facility radiologist.

c. Patient 12, a 64 year old female, presented to the ED on May 5, 2015, with complaints of back pain. A two view chest x-ray (CXR) was ordered by the ED physician and completed at 3:40 p.m. There was no initial interpretation completed by the ED physician.

Patient 12 was discharged home by the ED physician at 3:49 a.m., with a diagnosis of thoracic (middle back/chest) strain, and a prescription for a non-narcotic pain reliever.

A radiology discrepancy report dictated at 7:43 a.m., indicated Patient 12 had a 1 cm nodular density (mass) in the anterior chest area. The facility radiologist recommended a CT of the chest to further evaluate the finding.

There was no indication on the log the discrepancy was ever seen, reviewed, or followed up on by the ED provider.

A review of the record for Patient 12 indicated no documentation was present regarding the recommendations made by the facility radiologist.

d. Patient 13, an 86 year old male, presented to the ED on April 28, 2015, with altered mental status and vomiting.

A CT of the abdomen and pelvis was ordered by the ED physician and the initial interpretation was completed by the teleradiology physician at 6:09 a.m.

The initial interpretation included small bowel distention with possible bowel obstruction, distended urinary bladder, and no evidence of abdominal aortic aneurysm (AAA) (a bulge in a section of the aorta, the body's main artery, caused by a weakening of the wall of the artery).

A radiology discrepancy report dictated at 7:07 a.m., indicated, in addition to the above findings, the facility radiologist saw, "In addition to telerad(iology) prelim(inary) findings, there IS an AAA measuring 3.6 cm (centimeters)."

There was no indication on the log the discrepancy was ever seen, reviewed, or followed up on by the ED provider.

A review of the record for Patient 13 indicated no documentation was present regarding follow-up for the AAA.

During an interview with the ED Medical Director (EDMD) on May 11, 2015, at 2:30 p.m., the EDMD stated he was involved in the review and revision of the radiology discrepancy policy, completed in March 2015. The EDMD stated when there was a, "significant," radiology discrepancy, the facility radiologist called the ED provider and placed the discrepancy on the log.

He stated, if the discrepancy was not significant, the discrepancy was just put onto the log. The EDMD stated the ED physicians should be entering their interpretation of x-rays into the radiology computer system, and he had been reminding them of that, but their passwords had recently been inactivated due to a computer problem, and they were not able to get into the system for some time.

According to the EDMD, the mid-level provider (Physician Assistant) should be reviewing the discrepancy log daily. He stated the log was very long, and there was no way to know whether a discrepancy was seen or addressed, as the discrepancy stayed on the log and did not drop off. The EDMD stated a review of the discrepancy, review of treatment that was provided, whether or not follow up care was needed, and whether the patient was contacted for follow-up care should be documented in the electronic medical record (EMR).

According to the EDMD, no monitoring was being done to ensure the system put into place was being followed and was effective in providing continuity of care to patients. He stated there was no monitoring for contents of the log, compliance with addressing the discrepancies on the log, or whether there were trends developing that could identify opportunities for improvement (common physician, common test, common time).

The EDMD stated Patients 9, 12, and 13 should have been contacted by the ED provider to make them aware of the radiologist's findings so they would know to follow up with their primary care physicians.

2. During an interview with the Interim Director of the Emergency Department (IDED) on May 11, 2015, at 9 a.m., the IDED stated, when cultures were taken in the ED, the results were not released for 24 to 72 hours. The IDED stated when a culture was positive, the charge nurse (CN) in the ED received a phone call from the lab and took the information regarding the, "critical lab value," over the phone. According to the IDED, the CN would take the information to the ED physician who would look up the patient's information, determine whether treatment was indicated, and call the patient if necessary. She stated she did not know if there was a log in the department or the facility where the positive cultures were tracked and monitored for follow up.

During a tour of the Laboratory on May 11, 2015, at 10:10 a.m., accompanied by the Laboratory Manager, the manager stated positive blood culture results were considered a critical lab value, so all positive blood culture results were hand delivered to the ED provider on paper, with a second paper placed in a binder in the ED. The manager did not verbalize a system for reporting other positive culture results (urine, wound).

During an interview with the ED Charge Nurse (EDCN) 1 on May 11, 2015, at 10:20 a.m., the CN stated there was a blood culture book in the ED that contained positive blood culture information, but they did not look at or hear about any other positive cultures. The CN stated if the patient was discharged from the ED and a positive culture result (other than blood) was identified after discharge, she did not know what the process was, but the results were not called to or communicated to the ED.

During an interview with the Laboratory Medical Director (LMD) on May 11, 2015, at 10:25 a.m., the LMD stated the lab was not responsible for reporting non-critical results to the ED. He stated the lab did not report positive culture results, with the exception of blood cultures. The LMD stated the ED physicians had the same responsibility as other physicians who ordered lab tests, and if they ordered the test, they were responsible for reviewing the results when they came in. The LMD stated, "They need to look for them."

During an interview with the Infection Control Practitioner (ICP) on May 11, 2015, at 10:40 a.m., the ICP stated she received a daily report of all positive cultures (blood, wound, urine, nares, stool) that were results for patients throughout the facility, including ED patients. The ICP stated she reviewed the ED patient's culture results for the purposes of reporting to Public Health, but she was not responsible for completing or overseeing the follow-up with the discharged patients.

A review of the Infection Control Positive Culture Worksheet indicated the following:

a. Patient 3, a 59 year old male, presented to the ED on April 24, 2015, with a Foley catheter (tube in the bladder to drain urine) and complaints of abdominal pain. A urine test and culture were sent to the lab, the patient was diagnosed with a urinary tract infection, and discharged home with antibiotics.

Culture results, released on April 27, 2015, indicated Patient 3 had two different bacteria growing in his urine (escherichia coli and serratia marcescens), one that was resistant to the antibiotic he was prescribed (the antibiotic would not kill the bacteria).

The record for Patient 3 was reviewed on May 11, 2015. There was no evidence the culture results were reported to the ED. There was no evidence the urine culture results were reviewed by an ED provider. There was no evidence follow-up care was considered, attempted, or completed.

b. Patient 8, a 59 year old male, presented to the ED on May 2, 2015, with a Foley catheter (tube in the bladder to drain urine) and complaints of groin pain following prostate surgery. The patient was evaluated and discharged home with diagnoses that included groin pain, urinary retention, and dehydration.

Patient 8 returned to the ED on May 3, 2015 (the following day), with complaints of pain when attempting to urinate. Urine was collected and sent for analysis and culture. The patient was discharged home with a diagnosis of urinary tract infection, to continue taking the medications he was currently on.

Culture results, released on May 5, 2015, indicated Patient 8 had bacteria growing in his urine (proteus mirabilis) that was resistant to multiple antibiotics.

The record for Patient 8 was reviewed on May 11, 2015. There was no evidence the culture results were reported to the ED. There was no evidence the urine culture results were reviewed by an ED provider. There was no evidence follow-up care was considered, attempted, or completed.

c. Patient 10, a 3 year old male, presented to the ED on May 2, 2015, with a history of urinary tract infection. His temperature was 103 degrees Fahrenheit. Urine was collected and sent to the lab for analysis and culture. The patient was discharged home with a diagnosis of urinary tract infection, and prescribed antibiotics to treat it.

Culture results, released on May 4, 2015, indicated Patient 10 had bacteria growing in his urine (pseudomonas aeruginosa) that was resistant to the antibiotic he was prescribed (the antibiotic would not kill the bacteria).

The record for Patient 10 was reviewed on May 11, 2015. There was no evidence the culture results were reported to the ED. There was no evidence the urine culture results were reviewed by an ED provider. There was no evidence follow-up care was considered, attempted, or completed.

During an interview with the ED Medical Director (EDMD) on May 11, 2015, at 2:30 p.m., the EDMD stated he was involved in the review and revision of the positive culture policy, completed in March 2015. The EDMD stated when there was a positive culture result, the lab was to notify the ED provider or CN, who would communicate the information to the ED mid level provider. According to the EDMD, the mid level provider would review the information and the medical record, determine whether follow-up should be done, take appropriate action, then document the information in the EMR.

The EDMD stated he was not aware the lab was not notifying the ED for positive culture results other than blood cultures. According to the EDMD, no monitoring was being done to ensure the system that was put into place was being followed and was effective in providing continuity of care to patients who needed it. The EDMD stated Patients 3 and 10 should have had follow-up care provided, and Patient 8's EMR should have been reviewed for consideration of whether follow-up care was necessary.

During an interview with the Regional Director of Quality (RDQ) and the Chief Medical Officer (CMO) on May 12, 2015, at 2:30 p.m., the RDQ stated the facility did not have a process in place to collect, measure, monitor, and analyze data when positive culture results were obtained for patients who were seen and discharged from the ED.

During a concurrent interview with the CMO, the CMO stated the facility did have a policy in which the nurse was to notify the physician of positive culture results. The CMO stated,"This data was not included in quality. As far as I know there was no follow up to cultures taken in the emergency room other than blood cultures." The CMO stated,"We need to put some changes in place for radiology discrepancies."

The facility policy titled, "Discrepancies, Radiological and Abnormal Cultures," was reviewed on May 11, 2015. The policy indicated the following:

A. The purpose was to establish a procedure for addressing abnormal culture results and radiology discrepancies;

B. Abnormal culture and/or sensitivity results and radiological interpretation discrepancies were to be communicated directly to the ED provider as soon as the results were available to ensure timely and appropriate follow-up and treatment;

C. If an x-ray was read by the radiologist and the result was different than the ED provider's reading, the patient would be contacted (if deemed necessary) by the ED provider;

D. If an abnormal culture and/or sensitivity result was obtained by the laboratory, the ED provider or Registered Nurse (RN) would be notified by the Laboratory Technician with the patient's name and results;

E. The ED provider would review the electronic medical record (EMR) to determine the treatment the patient received. If the treatment was appropriate, no further intervention would be required. If the treatment was not appropriate, the ED provider would contact the patient (by telephone, by mail, or by use of the police) and request that they return to the ED for further evaluation and/or treatment; and,

F. All activities would be documented in the EMR.

Based on interview and record review the facility leadership failed to ensure the Ongoing Professional Practice Evaluation (OPPE) profiles were completed and/or reviewed by the Department Chair or the Chief of Staff per facility policy and procedure. This had the potential to result in the medical staff, administration and Govering Body not identifying opportunities for practice and performance inprovement.

Findings:

1a. On May 12, 2015, at 11:35 a.m., the credential file for Physician 3 was reviewed with the Director Medical Staff Services (DMSS).

Physician 3's file contained an OPPE profile for January 2012 through December 2012, and September 2014 through February 2015. The signature line on both OPPE profiles, indicating the OPPE had been reviewed by the Department Chair or the Chief of Staff, was blank.

There was no indication the OPPE profiles was reviewed by the Department Chair or the Chief of Staff.

There was no indication an OPPE profile occurred from January 2013 until September 2014 (20 months).

b. On May 12, 2015, at 11:40 a.m., the credential file for PA 3 was reviewed with the DMSS.

PA 3's initial service authorization occurred in November 2010.

PA 3's file contained one OPPE profile which covered January 2013 through June 2014 (three cycles in the OPPE process). The signature line, indicating the OPPE profile was reviewed by the Department Chair, was blank.

There was no indication the OPPE profile was reviewed by the Department Chair.

There was no indication an OPPE profile had occurred since June 2014.

During a concurrent interview with the DMSS, she stated the Quality Department generated the OPPE profiles every six months for each provider to include Allied Health Professionals, and this had been an inconsistent process over the last several years.

The DMSS stated the OPPE profiles were provided to the Medical Staff Department and each OPPE profile was reviewed by the Department Chair or the Chief of Staff. The DMSS stated the facility recently went to a process where the providers' OPPE profiles would be staggered so an OPPE profile would be generated that was close to the provider's reappointment date and the Medical Staff Department would not receive all of the OPPE profiles for the providers in the same month twice a year. The DMSS stated each provider should have an OPPE profile generated every six months, and each OPPE profile should be reviewed by the Department Chair and contain the signature of the reviewer.

The facility policy and procedure titled "Ongoing Professional Practice Evaluation (OPPE)/Focus Professional Practice Evaluation (FPPE)" revised February 2014, revealed "... Assure that the process for professional practice evaluation is clearly defined, objective, equitable, defensible, timely, and useful. Identify opportunities for practice and performance improvement of individual practitioners, including Allied Health Professionals. ... Ongoing review and findings about practitioner practice and performance are evaluated by the Medical Staff with the focus on improving quality outcomes and promoting safe patient care. ... The Quality Management department will generate OPPE profiles every 6 months. Data will be presented to the Department Chairman for review. The Department Chair will review the information in the physician profiles (to) determine if corrective actions are necessary. If a practitioner is identified (as needing corrective action) the practitioner will be referred to the Quality Review Committee for actions as necessary. ..."

28294

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

1. To ensure Emergency Services were integrated with Laboratory and Radiology services when:

a. Radiology discrepancies (differences) between the Emergency Department (ED) physician or teleradiologist (radiologist who reads studies on-line), and the facility radiologist were not reviewed to determine whether follow-up care was necessary and appropriate action was taken. (Refer to A1103); and

b. Urine and wound cultures/sensitivities (determination of bacteria present and effective antibiotic(s)) that were done in the ED and determined to be positive after the patient was discharged home were not reviewed to determine whether follow-up care was necessary and appropriate action was taken. (Refer to A1103);

2. To ensure Emergency Department (ED) nurses triaged patients in accordance with the nationally recognized ESI (Emergency Severity Index) standards, including consideration of both subjective and objective assessment information for two sampled patients (Patients 23 and 30). (Refer to A1104);

3. To ensure the assessment/reassessment of ED patients occurred per facility policy and procedure for two sampled patients (Patients 17 and 28). (Refer to A1104);

4. To ensure the physician's order for a bladder scan was followed and the patient's output was recorded once a Foley catheter (tube placed to drain urine from the bladder) was placed for one sampled patient (Patient 24). (Refer to A1104);

5. To ensure Emergency Department (ED) Registered Nurses (RNs) were educated, and achieved a passing score, on the ESI triage process and assessment/reassessment of the ED patient, before assuming the pivot/triage role in the ED according to the facility policy and procedure. (Refer to A1104);

6. To ensure two of two sampled Emergency Department providers [Physician 3 and Physician Assistant (PA) 3] Ongoing Professional Practice Evaluation [OPPE] profiles were completed and/or reviewed by the Department Chair or the Chief of Staff per facility policy and procedure. (Refer to A1112); and

7. To ensure two of two sampled Emergency Department Allied Healthcare Professionals [Physician Assistants (PA) 3 and 4] had current Basic Life Support [BLS] certification. (Refer to A1112).

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

Based on interview and record review, the facility failed to ensure Emergency Services were integrated with Laboratory and Radiology services when:

1. Radiology discrepancies (differences) between the Emergency Department (ED) physician or teleradiologist (radiologist who reads studies on-line), and the facility radiologist were not reviewed to determine whether follow-up care was necessary and appropriate action was taken; and,

2. Urine and wound cultures/sensitivities (determination of bacteria present and effective antibiotic(s)) that were done in the ED and determined to be positive after the patient was discharged home were not reviewed to determine whether follow-up care was necessary and appropriate action was taken.

These failed practices resulted in:

1. Three patients with positive radiological findings not being notified to follow up with their physicians (Patients 9, 12, and 13), and the potential for life threatening radiological findings (fractures, tumors, aneurysms) to go untreated; and,

2. Improper treatment of three patients with infections (Patients 3, 8, and 10) with no follow up communication from the ED, and the potential for life threatening infections to go untreated.

Findings:

1. During an interview with the Interim Director of the Emergency Department (IDED) on May 11, 2015, at 9 a.m., the IDED stated an on-line teleradiology group read the after hours x-rays (done after 7 p.m.). The director stated she did not know if the group read all x-rays or just the Computed Tomography (CT), Ultrasound (US), and Magnetic Resonance Imaging (MRI) studies. She stated the facility radiologist re-read x-rays the next day, but she did not know if all of the radiology procedures were re-read (those read by the teleradiology physician, those read by the ED physician, or both). According to the IDED, if there was a discrepancy between the original x-ray interpretation and the interpretation done by the facility radiologist, the facility radiologist would identify it, but she was, "not sure," what the process was for communicating and resolving x-ray discrepancies.

During a tour of the Radiology Department on May 11, 2015, at 9:25 a.m., accompanied by the Chief Radiology Technologist (CRT) and the Director of Imaging Services (DIS), the CRT stated the ED physicians read all plain films (x-rays) after 7 p.m. on weekdays and after 6 p.m. on weekends.

The CRT stated all CT, US, and MRI studies were read by a teleradiologist during those hours. According to the CRT, all after hours x-rays and radiology studies were re-read the following day by the facility radiologist. The CRT stated ED physicians were required to put their interpretation of the x-ray into the radiology computer system, and teleradiology physicians were required to scan their interpretation into the computer system, so the facility radiologist would be able to see if he/she agreed with the interpretation during the re-read.

The CRT stated if the facility radiologist's interpretation was different than that of the ED physician or the teleradiologist, a discrepancy would be logged in the radiology computer system on the, "discrepancy log."

A review of the discrepancy log on May 11, 2015, indicated hundreds of discrepancies were logged by the facility radiologists, with no evidence they were seen, reviewed, or acted on by the ED providers.

The DIS stated, if an ED physician failed to enter an interpretation of the x-ray into the radiology system, the radiologist would enter that as a discrepancy on the log. According to the DIS, many or all of the logged discrepancies could have been entered as a result of the ED physician failing to enter an interpretation, and may not reflect a positive finding or actual discrepancy.

The CRT stated if the discrepancy was addressed by the ED provider, there was no mechanism for the provider to indicate that on the log, and the discrepancy would not drop off of the log. According to the CRT, there was no way to know if any or all of the discrepancies had been addressed.

The CRT and the DIS stated they did not monitor the contents of the log, compliance with addressing the discrepancies on the log, or whether there were trends developing that could identify opportunities for improvement (common physician, common test, common time). The CRT and the DIS stated monitoring of the process was not their responsibility, it was the responsibility of the ED.

During an interview with Radiologist 1 on May 11, 2015, at 9:40 a.m., the radiologist stated if he saw a discrepancy in the after hours reading of an x-ray or radiology study, he would enter it onto the discrepancy log. He stated if the discrepancy was, "significant," he would call the ED and speak to the provider about it in addition to entering it onto the log.

According to the radiologist, there was not always an interpretation entered into the system by the ED physician, so he had no way of knowing what the ED physician diagnosed the patient with or treated the patient for. The radiologist stated he attended the radiology medical staff committee meetings, and he did not recall any discussions of the radiology discrepancy process.

He stated he did not know if the process was being monitored for contents of the log, compliance with addressing the discrepancies on the log, or whether there were trends developing that could identify opportunities for improvement (common physician, common test, common time).

A review of the contents of the discrepancy log on May 11, 2015, indicated the following:

a. 11 of 11 after hours x-rays ordered by the ED physicians, and completed during the time the ED physicians were required to read them, did not have an initial interpretation documented in the radiology system. There was no mechanism for the facility radiologist to know what the ED physician diagnosed the patient with or treated the patient for.

All 11 interpretations by the facility radiologist were entered onto the discrepancy log in the absence of an initial interpretation by the ED physician. There was no evidence an ED provider reviewed the discrepancies to determine whether the ED physician diagnosed and treated the patients correctly;

b. Patient 9, an 8 year old male, presented to the ED on May 4, 2015, with complaints of fever with shortness of breath and nausea. A CT of the abdomen and pelvis was ordered by the ED physician and the initial interpretation was completed by the teleradiology physician at 6:20 a.m.

The initial interpretation included right lower lobe infiltrates (pneumonia), splenomegaly (enlarged spleen), a normal appendix, and mesenteric adenitis (inflammation of the lymph nodes in the right side of the abdomen).

A radiology discrepancy report dictated at 8:31 a.m., indicated in addition to the above findings, the facility radiologist saw a masslike density in the right lower lobe of the lung as well as borderline enlargement of the appendix. The radiologist recommended the patient receive follow-up for both of these findings.

There was no indication on the log the discrepancy was ever seen, reviewed, or followed up on by the ED provider.

A review of the record for Patient 9 indicated no documentation was present regarding the recommendations made by the facility radiologist.

c. Patient 12, a 64 year old female, presented to the ED on May 5, 2015, with complaints of back pain. A two view chest x-ray (CXR) was ordered by the ED physician and completed at 3:40 p.m. There was no initial interpretation completed by the ED physician.

Patient 12 was discharged home by the ED physician at 3:49 a.m., with a diagnosis of thoracic (middle back/chest) strain, and a prescription for a non-narcotic pain reliever.

A radiology discrepancy report dictated at 7:43 a.m., indicated Patient 12 had a 1 cm nodular density (mass) in the anterior chest area. The facility radiologist recommended a CT of the chest to further evaluate the finding.

There was no indication on the log the discrepancy was ever seen, reviewed, or followed up on by the ED provider.

A review of the record for Patient 12 indicated no documentation was present regarding the recommendations made by the facility radiologist.

d. Patient 13, an 86 year old male, presented to the ED on April 28, 2015, with altered mental status and vomiting.A CT of the abdomen and pelvis was ordered by the ED physician and the initial interpretation was completed by the teleradiology physician at 6:09 a.m.

The initial interpretation included small bowel distention with possible bowel obstruction, distended urinary bladder, and no evidence of abdominal aortic aneurysm (AAA) (a bulge in a section of the aorta, the body's main artery, caused by a weakening of the wall of the artery).

A radiology discrepancy report dictated at 7:07 a.m., indicated, in addition to the above findings, the facility radiologist saw, "In addition to telerad(iology) prelim(inary) findings, there IS an AAA measuring 3.6 cm (centimeters)."

There was no indication on the log the discrepancy was ever seen, reviewed, or followed up on by the ED provider.

A review of the record for Patient 13 indicated no documentation was present regarding follow-up for the AAA.

During an interview with the ED Medical Director (EDMD) on May 11, 2015, at 2:30 p.m., the EDMD stated he was involved in the review and revision of the radiology discrepancy policy, completed in March 2015.

The EDMD stated when there was a, "significant," radiology discrepancy, the facility radiologist called the ED provider and placed the discrepancy on the log. He stated if the discrepancy was not significant, the discrepancy was just put onto the log.

The EDMD stated the ED physicians should be entering their interpretation of x-rays into the radiology computer system, and he had been reminding them of that, but their passwords had recently been inactivated due to a computer problem, and they were not able to get into the system for some time.

According to the EDMD, the mid-level provider (Physician Assistant) should be reviewing the discrepancy log daily. He stated the log was very long, and there was no way to know whether a discrepancy was seen or addressed, as the discrepancy stayed on the log and did not drop off. The EDMD stated a review of the discrepancy, review of treatment that was provided, whether or not follow up care was needed, and whether the patient was contacted for follow-up care should be documented in the electronic medical record (EMR).

According to the EDMD, no monitoring was being done to ensure the system was being followed and was effective in providing continuity of care to patients. He stated there was no monitoring for contents of the log, compliance with addressing the discrepancies on the log, or whether there were trends developing that could identify opportunities for improvement (common physician, common test, common time).

The EDMD stated Patients 9, 12, and 13 should have been contacted by the ED provider to make them aware of the radiologist's findings so they would know to follow up with their primary care physicians.

2. During an interview with the Interim Director of the Emergency Department (IDED) on May 11, 2015, at 9 a.m., the IDED stated when cultures were taken in the ED, the results were not released for 24 to 72 hours. The IDED stated when a culture was positive, the charge nurse (CN) in the ED received a phone call from the lab and took the information regarding the, "critical lab value," over the phone.

According to the IDED, the CN would take the information to the ED physician, who would look up the patient's information, determine whether treatment was indicated, and call the patient if necessary. She stated she did not know if there was a log where the positive cultures were tracked and monitored for follow up.

During a tour of the Laboratory on May 11, 2015, at 10:10 a.m., accompanied by the Laboratory Manager, the manager stated positive blood culture results were considered a critical lab value, so all positive blood culture results were hand delivered to the ED provider on paper, with a second paper placed in a binder in the ED. The manager did not verbalize a system for reporting other positive culture results (urine, wound).

During an interview with the ED Charge Nurse (EDCN 1) on May 11, 2015, at 10:20 a.m., the CN stated there was a blood culture book in the ED that contained positive blood culture information, but they did not look at or hear about any other positive cultures.

The CN stated if the patient was discharged from the ED and a positive culture result (other than blood) was identified after discharge, she did not know what the process was, but the results were not called to or communicated with the ED.

During an interview with the Laboratory Medical Director (LMD) on May 11, 2015, at 10:25 a.m., the LMD stated the lab was not responsible for reporting non-critical results to the ED. He stated the lab did not report positive culture results, with the exception of blood cultures.

The LMD stated the ED physicians had the same responsibility as other physicians who ordered lab tests, and if they ordered the test, they were responsible for reviewing the results when they came in. The LMD stated, "They need to look for them."

During an interview with the Infection Control Practitioner (ICP) on May 11, 2015, at 10:40 a.m., the ICP stated she received a daily report of all positive cultures (blood, wound, urine, nares, stool) that were results for patients throughout the facility, including ED patients. The ICP stated she reviewed the ED patient's culture results for the purposes of reporting to Public Health, but she was not responsible for completing or overseeing the follow-up with the discharged patients.

A review of the Infection Control Positive Culture Worksheet indicated the following:

a. Patient 3, a 59 year old male, presented to the ED on April 24, 2015, with a foley catheter (tube in the bladder to drain urine) and complaints of abdominal pain. A urine test and culture were sent to the lab, the patient was diagnosed with a urinary tract infection, and discharged home with antibiotics.

Culture results, released on April 27, 2015, indicated Patient 3 had two different bacteria growing in his urine (escherichia coli and serratia marcescens), one that was resistant to the antibiotic he was prescribed (the antibiotic would not kill the bacteria).

The record for Patient 3 was reviewed on May 11, 2015. There was no evidence the culture results were reported to the ED. There was no evidence the urine culture results were reviewed by an ED provider. There was no evidence follow-up care was considered, attempted, or completed.

b. Patient 8, a 59 year old male, presented to the ED on May 2, 2015, with a foley catheter (tube in the bladder to drain urine) and complaints of groin pain following prostate surgery. The patient was evaluated and discharged home with diagnoses that included groin pain, urinary retention, and dehydration.

Patient 8 returned to the ED on May 3, 2015 (the following day), with complaints of pain when attempting to urinate. Urine was collected and sent for analysis and culture. The patient was discharged home with a diagnosis of urinary tract infection, and orders to continue taking the medications he was currently on.

Culture results, released on May 5, 2015, indicated Patient 8 had bacteria growing in his urine (proteus mirabilis) that was resistant to multiple antibiotics.

The record for Patient 8 was reviewed on May 11, 2015. There was no evidence the culture results were reported to the ED. There was no evidence the urine culture results were reviewed by an ED provider. There was no evidence follow-up care was considered, attempted, or completed.

c. Patient 10, a 3 year old male, presented to the ED on May 2, 2015, with a history of urinary tract infection. His temperature was 103 degrees Fahrenheit. Urine was collected and sent to the lab for analysis and culture. The patient was discharged home with a diagnosis of urinary tract infection, and prescribed antibiotics to treat the infection.

Culture results, released on May 4, 2015, indicated Patient 10 had bacteria growing in his urine (pseudomonas aeruginosa) that was resistant to the antibiotic he was prescribed (the antibiotic would not kill the bacteria).

The record for Patient 10 was reviewed on May 11, 2015. There was no evidence the culture results were reported to the ED. There was no evidence the urine culture results were reviewed by an ED provider. There was no evidence follow-up care was considered, attempted, or completed.

During an interview with the ED Medical Director (EDMD) on May 11, 2015, at 2:30 p.m., the EDMD stated he was involved in the review and revision of the positive culture policy, completed in March 2015.

The EDMD stated, when there was a positive culture result, the lab was to notify the ED provider or CN, who would communicate the information to the ED mid level provider.

According to the EDMD, the mid level provider would review the information and the medical record, determine whether follow-up should be done, take appropriate action, then document the information in the EMR. The EDMD stated he was not aware the lab was not notifying the ED for positive culture results other than blood cultures.

According to the EDMD, no monitoring was being done to ensure the system put into place was being followed and was effective in providing continuity of care to patients.

The EDMD stated Patients 3 and 10 should have had follow-up care provided, and Patient 8's EMR should have been reviewed for consideration of whether follow-up care was necessary.

The facility policy titled, "Discrepancies, Radiological and Abnormal Cultures," was reviewed on May 11, 2015. The policy indicated the following:

A. The purpose was to establish a procedure for addressing abnormal culture results and radiology discrepancies;

B. Abnormal culture and/or sensitivity results and radiological interpretation discrepancies were to be communicated directly to the ED provider as soon as the results were available to ensure timely and appropriate follow-up and treatment;

C. If an x-ray was read by the radiologist and the result was different than the ED provider's reading, the patient would be contacted (if deemed necessary) by the ED provider;

D. If an abnormal culture and/or sensitivity result was obtained by the laboratory, the ED provider or Registered Nurse (RN) would be notified by the Laboratory Technician with the patient's name and results;

E. The ED provider would review the electronic medical record (EMR) to determine the treatment the patient received. If the treatment was appropriate, no further intervention would be required. If the treatment was not appropriate, the ED provider would contact the patient (by telephone, by mail, or by use of the police) and request that they return to the ED for further evaluation and/or treatment; and,

F. All activities would be documented in the EMR.

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

1. To ensure Emergency Department (ED) nurses triaged patients in accordance with the nationally recognized ESI (Emergency Severity Index) standards, including consideration of both subjective and objective assessment information for two sampled patients (Patients 23 and 30). This had the potential to result in delays in care, harm, or death;

2. To ensure the assessment/reassessment of ED patients occurred per facility policy and procedure for two sampled patients (Patients 17 and 28). This had the potential to result in delays in care and deterioration in the patients' conditions;

3. To ensure the physician's order for a bladder scan was followed and the patient's output was recorded once a Foley catheter (tube placed to drain urine from the bladder) was placed for one sampled patient (Patient 24). This resulted in the physician's order not being followed, no indication of the volume in the bladder prior to catheterization; and no indication of how much urine was removed from the bladder, and a description of the characteristics of the urine; and

4. To ensure Emergency Department (ED) Registered Nurses (RNs) were educated, and achieved a passing score, on the ESI triage process and assessment/reassessment of the ED patient, before assuming the pivot/triage role in the ED according to the facility policy and procedure. This had the potential to result in the ED patients being triaged, assessed, and reassessed in appropriately with potential delays in treatment, harm, or death.

Findings:

1. The ESI is a five level triage algorithm that categorizes ED patients by evaluating both acuity and resource needs (different from the older systems that considered only patient acuity). Initially, the triage nurse assess only the acuity level. If a patient does not meet the high acuity level (ESI level one or two), the triage nurse then evaluates expected resource needs to help determine a triage level (level three, four, or five). The ESI is intended for use by nurses with triage experience, or those who have attended a separate, comprehensive triage educational program.

ESI level one patients are patients who will die without immediate intervention, where the patient's vital signs or major organs are compromised (airway, breathing, or circulation to the heart or brain).

ESI level two patients are ill and at high risk for deteriorating, and placement in an ED bed should be initiated rapidly (Patients who are suicidal, homicidal, or psychotic are level two patients). The triage nurse will rely on a brief interview with the patient (subjective assessment information) as well as the patient's appearance, age, medical history, and current medications (objective assessment information) .

ESI level three patients are ill, but can wait in the lobby for medical evaluation and treatment. The triage nurse will consider the subjective and objective assessment information (chief complaint, appearance, behavior, past medical history, current medications), as well as the patient's vital signs. ESI level three patients have stable vital signs, and will require a workup using two or more resources (lab, radiology, intravenous therapy). Patients who's vital signs are outside of the normal ranges (example: a child 3 months to 3 years with a temperature greater than 102.2 degrees Fahrenheit with no obvious source of infection, an adult with a respiratory rate greater than 20) should be strongly considered for elevation to an ESI level two.

ESI level four patients are stable and will require only one resource in addition to the medical examination and treatment.

ESI level five patients are stable, and will not require any resources in addition to the medical evaluation and treatment.

To help ensure successful adoption of the ESI level triage system in the ED, a well thought out implementation plan is critical. Implementation takes time, careful planning, and a group of professionals dedicated to a successful transition.

All triage policies must be reviewed, and many policies may need to be rewritten. Decisions regarding reassessment times need to be incorporated into the triage policies.

Education is one of the critical tasks required for implementation of the ESI triage system. Triage nursing staff will need a full orientation to the system, as several key concepts need to be understood in order to maintain the reliability and validity of the process.

Emergency Severity Index (ESI), A Triage Tool for Emergency Department Care, Version 4, Implementation Handbook, 2012 Edition. (Agency for Healthcare Research and Quality [AHRQ]).

a. On May 11, 2015, the record for Patient 23 was reviewed. Patient 23 presented to the facility Emergency Department (ED) with her mother on May 11, 2015, at 11:10 p.m. Patient 23's record indicated her chief complaint was attempted suicide by swallowing 6 Celexa pills (anti-depressant medication) and 8 BuSpar (anti-anxiety medication).

The triage note, completed by Registered Nurse (RN) 2, indicated Patient 23 was assigned an ESI level 3 (urgent but not life threatening). Patient 23 was assigned a sitter for 1 to 1 observation for patient safety. Patient 23 had intravenous (IV) fluid started.

During an interview with the Interim Director Emergency Department (IDED), on May 12, 2015, at 10:30 a.m., the IDED reviewed the record for Patient 23. The IDED stated based on the patient's assessment, acuity, and resources needed, "The ESI should have been a level 2 relating to her suicide attempt and having a sitter at the bedside."

b. On May 11, 2015, the record for Patient 30 was reviewed. Patient 30 presented to the facility ED on May 2, 2015, at 1:38 p.m., with the chief complaint of abdominal pain.

Patient 30 arrived at the facility via ambulance and had been treated in the field with intravenous (IV) fluids and an IV medication for nausea.

At 1:52 p.m., Patient 30's respiratory rate was 24 and the patient reported epigastric pain at a level of 10/10 (on a scale of 0 to 10 with 10 being the worst pain).

At 1:54 p.m., Patient 30 was assigned an ESI level 4 - less urgent by Registered Nurse (RN) 5.

During an interview with the Interim Director Emergency Department (IDED), on May 12, 2015, at 10:30 a.m., she reviewed the record for Patient 30. The IDED stated based on the patient's assessment, acuity, and resources needed, Patient 30 should have been assigned an ESI level of at least a "3."

The facility policy and procedure titled "Triage" reviewed/revised February 2015, revealed "... ESI Level 2 patients are ill and at high risk for deteriorating, and placement in an ED bed should be initiated rapidly (Patients who are suicidal, homicidal, or psychotic are level two patients). The pivot nurse will rely on a brief interview with the patient (subjective assessment information) as well as the patient's appearance, age, medical history, and current medications (objective assessment information). ... Psychiatric complaints that require 1:1 observation. ... ESI Level 3 patients are ill, but can wait in the lobby for medical evaluation and treatment. The triage nurse will consider the subjective and objective assessment information (chief complaint, appearance, behavior, past medical history, current medications), as well as the patient's vital signs. ESI level three patients have stable vital signs, and will require a workup using two or more resources (lab, radiology, intravenous therapy). Patients who's vital signs are outside of the normal ranges (example: a child 3 months to 3 years with a temperature greater than 102.2 degrees Fahrenheit with no obvious source of infection, an adult with a respiratory rate greater than 20) should be strongly considered for elevation to an ESI level two. ESI Level 4: Stable and and are safe to wait. Patients requiring 1 resource only in addition to the medical screening examination and treatment. ..."

2a. On May 11, 2015, the record for Patient 17 was reviewed. Patient 17 presented to the facility Emergency Department by ambulance on May 5, 2015, at 10:13 a.m., with the complaint of seizures prior to arrival.

There was no evidence in the record of Patient 17's use of anti-seizure medications.

Patient 17 was discharged from the ED at 2: 02 p.m.

There was no documented indication Patient 17's vital signs, to include a pain assessment, had been assessed and reassessed during the patient's ED visit (three hours and 49 minutes). In addition, there was no indication Patient 17's vital signs and pain assessment were completed prior to the patient being discharged from the facility ED.

An interview was conducted with the Interim Director of the Emergency Department (IDED) on May 12, 2015, at 1:30 p.m. The IDED stated, "Vitals should have been completed with admission and as part of reassessment prior to discharge."

b. On May 11, 2015, the record for Patient 28 was reviewed. Patient 28 presented to the facility ED on May 11, 2015, at 7:26 a.m., with the chief complaint of bilateral leg swelling.

At 7:30 a.m., Patient 28's vital signs were taken/documented to include a pain level of "4" (on a scale of 0 to 10 with 10 being the worst pain), and was assigned an ESI level "3."

Patient 28 was seen by the physician at 8:20 a.m., and diagnostic laboratory and radiology tests were ordered.

The "Nursing Note" dated May 11, 2015, at 9:22 a.m., indicated "no change in condition."

At 1:52 p.m., Patient 28's vital signs were taken/documented to include a pain level of "5."

There was no indication Patient 28's vital signs or a pain reassessment were done between 7:30 a.m., and 1:52 p.m. (6 hours and 22 minutes).

There was no indication Patient 28's condition was reassessed between 9:22 a.m., and 1:52 p.m. (4 hours and 30 minutes).

At 2:30 p.m., the physician made the decision to admit Patient 28 to the facility, and the patient was transferred to the Medical/Surgical Unit on May 11, 2015, at 9:47 p.m.

During an interview with the Interim Director Emergency Department (IDED), on May 12, 2015, at 10:30 a.m., she reviewed the record and was unable to find documentation of a reassessment of Patient 28's vital signs and pain level between 7:30 a.m., and 1:52 p.m., and reassessment of Patient 28's status related to the patient's chief complaint between 9:22 a.m., and 1:52 p.m. The IDED stated Patient 28 should have been reassessed at least every two hours to include vital signs, pain level, and status related to the patient's chief complaint.

The facility policy and procedure titled "Patient Assessment and Reassessment" revised May 2015, revealed "... Emergency Department, Initial Assessment Initiated Upon Triage, Assessment and Reassessment, As indicated using the 5-level ESI Triage Acuity system level 1-5. ... Level 3: Every 2 hours ... Within 30 minutes prior to discharge. ..."

The facility policy and procedure titled "Triage" reviewed/revised February 2015, revealed "... Reassessment includes: Vital signs. Pain level and status related to the patient's chief complaint. The RN reassessing the patient will take appropriate action if there is a change in the patient's condition. ..."

3. On May 11, 2015, the record for Patient 24 was reviewed. Patient 24 presented to the facility ED on May 8, 2015, at 11:17 a.m., with the chief complaint of blood in his urine and lack of urinary output for three days.

Patient 24 had been seen at the facility ED on May 6, 2015, and was discharged from the ED with the diagnosis of urinary tract infection.

Patient 24 was "triaged" at 12:17 p.m., and was assigned an ESI level of "3."

Patient 24 was seen by the provider at 12:35 p.m., and a "bladder scan" was ordered to determine the volume of urine in the patient's bladder.

There was no indication in the record a "bladder scan" was completed or the order was canceled.

A "Urology Consult" dated May 8, 2015, at 9:45 p.m., indicated the reason for the consultation was "unable to pass the catheter secondary to urinary retention [stricture]." Patient 24 consented to a dilatation of the urethra due to a stricture and placement of a Foley catheter. The Urologist placed a 16 French catheter "which drained possibly a 1.5 liter of dark urine with blood clots removed."

There was no indication in the nursing record of the time of procedure, volume of urine removed, and the characteristics of the urine removed.

There was no indication of a urine output being recorded for Patient 24.

Patient 24 was discharged from the facility ED on May 8, 2015, at 10:35 p.m., with a Foley catheter in place.

During an interview with the Interim Director Emergency Department (IDED), on May 12, 2015, at 11:30 a.m., she reviewed the record and was unable to find documentation of a bladder scan being done per physician's order and Patient 24's urine output once a Foley catheter was placed. The IDED stated the bladder scan should have been done as ordered or the order should have been canceled if the physician no longer wanted the bladder scan done. In addition, the IDED stated the nurse should have recorded the output from the Foley catheter to include how much urine was removed, when the urine was removed, and the characteristics of the urine. The IDED stated Patient 24's Foley catheter should have been emptied prior to the patient being discharged from the facility.


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4. During a tour of the Emergency Department (ED) on May 11, 2015, at 9 a.m., an observation was conducted of the Emergency Room staff and patient flow. The pivot nurse, Registered Nurse (RN) 4, was assigned to take vital signs and determined a patient's ESI level. The triage nurse, Registered Nurse (RN) 1, completed the triage assessment, assisted with the treatment of patients, and assisted with bed placement.

Both staff members were observed admitting patients, assigning ESI levels, and assisting patients with care for a scheduled 12 hour shift.

A record review was conducted of the Emergency Room ESI training exam. The exam consisted of educational training of standard procedures in the ED which included assessment and reassessment, STAT medications (medications given in an emergency), titrating and tapering of medications, medication administration and monitoring, and ED triage which included determining ESI levels. The exam was to be completed prior to April 28, 2015.

A review of the training test scores indicated both the pivot nurse, RN 4, and the triage nurse, RN 1 both scored below the competency level (at or above 85%) required to perform ESI and the standard procedures of the Emergency Room..

Further record review was conducted on May 11, 2015, and indicated the following:

a. On May 11, 2015, the record for Patient 23 was reviewed. Patient 23 presented to the facility Emergency Department (ED) with her mother on May 11, 2015, at 11:10 p.m. Patient 23's record indicated her chief complaint was attempted suicide by swallowing 6 Celexa pills (anti-depressant medication) and 8 BuSpar (anti-anxiety medication).

The triage note, completed by Registered Nurse (RN) 2, indicated Patient 23 was assigned an ESI level 3 (urgent but not life threatening). Patient 23 was assigned a sitter for 1 to 1 observation for patient safety. Patient 23 had intravenous (IV) fluid started.

During an interview with the Interim Director Emergency Department (IDED), on May 12, 2015, at 10:30 a.m., the IDED reviewed the record for Patient 23. The IDED stated based on the patient's assessment, acuity, and resources needed, "The ESI should have been a level 2 relating to her suicide attempt and having a sitter at the bedside."

A review of the Emergency Department's list of nurses who had received and completed the ESI training packet indicated RN 2 was not listed as having completed the training.

b. On May 11, 2015, the record for Patient 30 was reviewed. Patient 30 presented to the facility ED on May 2, 2015, at 1:38 p.m., with the chief complaint of abdominal pain.

Patient 30 arrived at the facility via ambulance and had been treated in the field with intravenous (IV) fluids and an IV medication for nausea.

At 1:52 p.m., Patient 30's respiratory rate was 24 and the patient reported epigastric pain at a level of 10/10 (on a scale of 0 to 10 with 10 being the worst pain).

At 1:54 p.m., Patient 30 was assigned an ESI level 4 - less urgent by Registered Nurse (RN) 5.

During an interview with the Interim Director Emergency Department (IDED), on May 12, 2015, at 10:30 a.m., she reviewed the record for Patient 30. The IDED stated based on the patient's assessment, acuity, and resources needed, Patient 30 should have been assigned an ESI level of at least a "3."

A review of RN 5's education record indicated RN 5 had scored below the competency level on the facility's "Emergency Room ESI Triage Exam" taken on April 17, 2015.

The list of nurses who had received ESI level training before April 28, 2015, was reviewed on May 12, 2015. According to the list, 39 of approximately 65 nurses (more than 50% of the ED nursing staff) did not pass the ESI training course with a competency score at or greater than 85 percent. Only three nurses were re- educated by the ED Education Staff Developer and or the Interim Director of the ED.

There was no evidence that more than half of the ED nursing staff had demonstrated competency in triaging patients using the five tiered ESI system.

There was no evidence that half the staff was re-educated and re-tested to perform the skill of assigning patients in the triage at appropriate ESI levels.

The IDED acknowledged ED nursing staff who did not demonstrate competency with ESI training and standards of emergency room care, were currently assigned patients in the ED and were also assigning ESI levels to patients.

An interview was conducted with the Chief Nursing Officer (CNO) on May 12, 2015, at 2 p.m. The CNO stated,"Nurses should not be assigned patient's if they have not passed the test...they should not be doing triage or assigning ESI."The CNO stated,"We had found out through corporate that the competency score of any testing of employees should be 85 percent."

A review of the facility policy, "Competency Assessments/Certifications," indicated, "For clinical staff (an) evaluation includes an objective assessment of the individual's performance in delivering patient care service in accordance with patients' needs, patient population served, and culture. Qualified staff will communicate and/or provide appropriate patient care for all age groups routinely seen in the medical center...An employee who does not pass a competency receives education and is re-tested before they are allowed to perform this skill.

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Based on interview and record review the facility failed:

1. To ensure two of two sampled Emergency Department providers [Physician 3 and Physician Assistant (PA) 3] Ongoing Professional Practice Evaluation (OPPE) profiles were completed and/or reviewed by the Department Chair or the Chief of Staff per facility policy and procedure. This had the potential to result in the medical staff not identifying opportunities for practice and performance improvement; and

2. To ensure two of two sampled Emergency Department Allied Healthcare Professionals [Physician Assistants (PA) 3 and 4] had current Basic Life Support (BLS) certification. This resulted in PA 3 and 4 providing patient care without meeting the facility's requirements for BLS certification, and the potential for improper treatment of an airway, breathing or circulation problem.

Findings:

1 a. On May 12, 2015, at 11:35 a.m., the credential file for Physician 3 was reviewed with the Director Medical Staff Services (DMSS).

Physician 3's file contained an OPPE profile for January 2012 through December 2012, and September 2014 through February 2015. The signature line on both OPPE profiles, indicating the OPPE had been reviewed by the Department Chair or the Chief of Staff, was blank.

There was no indication the OPPE profiles had been reviewed by the Department Chair or the Chief of Staff.

There was no indication an OPPE profile had occurred from January 2013 until September 2014 (20 months).

b. On May 12, 2015, at 11:40 a.m., the credential file for PA 3 was reviewed with the DMSS.

PA 3's initial service authorization occurred in November 2010.

PA 3's file contained one OPPE profile which covered January 2013 through June 2014 (three cycles in the OPPE process). The signature line, indicating the OPPE profile had been reviewed by the Department Chair, was blank.

There was no indication the OPPE profile had been reviewed by the Department Chair.

There was no indication an OPPE profile had occurred since June 2014.

During a concurrent interview with the DMSS, she stated the Quality Department generated the OPPE profiles every six months for each provider to include Allied Health Professionals, and this had been an inconsistent process over the last several years.

The DMSS stated the OPPE profiles were provided to the Medical Staff Department and each OPPE profile was reviewed by the Department Chair or the Chief of Staff. The DMSS stated the facility recently changed to a process where the providers' OPPE profiles would be staggered so an OPPE profile would be generated that was close to the provider's reappointment date and the Medical Staff Department would then not receive all of the OPPE profiles for all of the providers in the same month twice a year.

The DMSS stated each provider should have an OPPE profile generated every six months, and each OPPE profile should be reviewed by the Department Chair and contain the signature of the reviewer.

The facility policy and procedure titled "Ongoing Professional Practice Evaluation (OPPE)/Focus Professional Practice Evaluation (FPPE)" revised February 2014, revealed, "... Assure that the process for professional practice evaluation is clearly defined, objective, equitable, defensible, timely, and useful. Identify opportunities for practice and performance improvement of individual practitioners, including Allied Health Professionals. ... Ongoing review and findings about practitioner practice and performance are evaluated by the Medical Staff with the focus on improving quality outcomes and promoting safe patient care. ... The Quality Management department will generate OPPE profiles every 6 months. Data will be presented to the Department Chairman for review. The Department Chair will review the information in the physician profiles (to) determine if corrective actions are necessary. If a practitioner is identified (as needing corrective action) the practitioner will be referred to the Quality Review Committee for actions as necessary. ..."

2a. On May 11, 2015, at 10 a.m., a tour of the Emergency Department (ED) was conducted. PA 3 was in the ED providing care to the ED patients.

During a concurrent interview with PA 3, she stated she was "perdiem" and worked about once a week in the ED as an Allied Health Professional provider.

On May 12, 2015, at 11:40 a.m., the credential file for PA 3 was reviewed with the Director Medical Staff Services (DMSS).

PA 3's initial service authorization occurred in November 2010, with the most recent service authorization granted for November 1, 2014, through October 31, 2016.

The BLS certification in PA 3's file indicated an expiration date of August 2012.

There was no indication PA 3 had current BLS certification.

b. On May 12, 2015, at 12 p.m., the credential file for PA 4 was reviewed with the DMSS.

PA 4 submitted his application on February 2, 2015, and was currently working in the ED as a "Locum Tenens."

PA 4 worked in the ED as an Allied Health Professional provider on March 13, 2015; April 5, 2015; April 23, 2015; April 27, 2015; and April 30, 2015.

There was no indication PA 4 had current BLS certification.

During a concurrent interview with the DMSS, she stated the Emergency Department's Physician Assistant certification requirements, for service authorization to practice at the facility, included a current BLS certification. The DMSS stated PA 3 and PA 4 should have current BLS certifications to practice at the facility and documentation of such should be maintained in their files.

The facility "Department of Emergency Medicine, Emergency Medicine - Physician Assistant, Practice Prerogatives" undated, revealed "... Licensure and Certification ... Current BLS and ACLS (Advanced Cardiovascular Life Support) certification. ..."