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This Condition is not met as evidenced by:

Based on review of facility documents, medical record (MR), camera video recording and interview with staff (EMP), it was determined that the hospital failed to ensure the safety and safe environment of a patient presenting to the emergency department transported by ambulance from a nursing home with Altered Change in Mental Status (A0144) and failed to ensure a documented reassessment of a patient triaged in the emergency department with an Emergency Severity Index Level 3 score presenting with Altered Change in Mental Status (1112).

On January 26, 2024, at 3:40 PM, Immediate Jeopardy (IJ) was identified for 482.13: Patient Rights. The hospital implemented immediate interventions to include an additional Registered Nurse to be placed in the emergency department external waiting room triage to support the primary triage nurse and completing assessment of patients every 4 hours; education provided to the external waiting area triage nurse, medical staff providers, charge nurse. The State Agency verified the immediate interventions and the IJ was removed.


Cross reference
482.13 (c)(2): Patient Rights: Care in Safe Setting
482.55 (b)(2): Qualified Emergency Services Personnel

Based on review of facility policy, security camera footage, medical record (MR) and interview with staff (EMP), it was determined that the facility failed to provided a safe environment in the emergency department (ED) by failing to ensure that a patient presenting to the emergency department with an Altered Change in Mental Status was in a safe location within the ED waiting room for one of one medical record reviewed (MR1).

Findings Include:

Review of facility policy "Patient Rights and Responsiblities, 112.09", last revised October 2023 revealed "...Each patient's personal dignity and self-worth are important to Thomas Jefferson University Hospital (TJUH). Patients have the right to be treated in a dignified and respectful manner by all TJUH personnel. This policy reflects TJUH's consideration of all patients cultural and personal values, beliefs and preferences and is designed to optimize their comfort and dignity. Patients have the right to be cared for by staff educated about patient rights and their role in supporting those rights....To Receive Quality Health Care: Patients have the right to excellent quality health care, maintained to the highest professional standards. In furtherance of that goal, TJUH continually monitors and reviews care rendered to patients and seeks ways to improve performance and quality.

Review of MR1 revealed the patient arrived to the Emergency Department via ambulance at the ambulance entrance on January 23, 2024, at 10:54 AM and was triage by a registered nurse on January 23, 2024, at 10:57 AM .Further review revealed the patient arrived from a nursing home presenting to the emergency department with Altered Mental Status, Urinary Track Infection (UTI) and Aggressive Behavior.

Review of MR1 revealed a progress note authored by EMP14,registered nurse on January 23, 2024, at 11:10 AM revealed "Altered Mental Status reported from Nursing Home. Nursing Home reports patient displays aggression."

Review of MR1 revealed a progress note authored by OTH1, physician assistant, on January 23, 2024, at 11:51 AM revealed " Patient presenting with change in Mental Status, aggressive behavior, "he/she" is not sure why "he/she" is in the emergency department..."he/she" states "he/she" is hungry."

Review of MR1 revealed documentation of a blood glucose test result dated January 23, 2024, at 12:05 PM. Further review of MR1 revealed the patient was assigned and seated in the external waiting room location at 12:05 PM in the emergency department.

Review of the facility's security camera footage received from the facility on January 27, 2024, to the survey team revealed the patient (MR1) exiting the emergency department external waiting room unassisted on January 24, 2024, at 12:11 AM.

An interview conducted on January 26, 2024, at 11:15 AM with EMP1 confirmed the medical record of MR1 contained no documentation of the patient's care and treatment after the blood glucose lab test resulted at 12:05 PM on January 23, 2024.

An interview conducted on January 26, 2024, at 11:52 AM with EMP15 confirmed an internal incident report was filed on January 24, 2024, at 2:57 AM reporting MR1 as a missing person. Further interview confirmed the emergency department staff was not aware as to when MR1 had exited the facility's emergency department waiting room and the patient's location after exiting. EMP15 confirmed the police and the patient's family member was notified of the patient's elopement from the emergency department external waiting room.

This Condition is not met as evidenced by:

Based on review of facility documents, medical record (MR), camera video recording and interview with staff (EMP), it was determined that the hospital failed to ensure a documented reassessment of a patient triaged in the emergency department with a Emergency Severity Index Level 3 score presenting with Altered Change in Mental Status (1112) and failed to ensure the safety and safe environment of a patient presenting to the emergency department transported by ambulance from a nursing home with Altered Change in Mental Status (A0144).

On January 26, 2024, at 3:40 PM, Immediate Jeopardy (IJ) was identified for 482.55: Emergency Services. The hospital implemented immediate interventions to include revision in the provider workflow for dispositioning a patient arriving via EMS/Ambulance to the external waiting room, treatment space and internal waiting room area; ambulance patients will be assigned to internal waiting room or treatment room; patient care technician assigned to the external waiting room 24/7 to round on patients every 2 hours and document in the electronic medical records the rounds completed. Rounding audits performed by the patient care technician will be audited by the Nurse Supervisor. The State Agency verified the immediate interventions and the IJ was removed.


Cross Reference:
482.55 (b)(2): Qualified Emergency Services Personnel
482.13 (c)(2): Patient Rights: Care in Safe Setting

Based on review of facility policy, security camera footage, medical record (MR) and interview with staff (EMP), it was determined that the facility failed to ensure the clinical healthcare staff performed a reassessment for care delivery according to the facility's policy as a standard of care for a patient in the emergency department with an Emergency Severity Index (ESI) Score: Level 3 presenting with Altered Change in Mental Status for one of one medical record reviewed (MR1).

Findings include:

Review of facility policy "Plan for Patient Assessment and Reassessment, 113.35" last revised December 2023 revealed "VIII. ASSESSMENT/REASSESSMENT CRITERIA revealed " The patient's diagnoses-treatment setting (ED, Intensive Care, OR, Med/Surg..... etc.) duration of care of length of stay, age and developmental needs, patient's desire for treatment and response to treatment all serve to direct the process of assessment and reassessment by members of the healthcare team. Criteria defining guidelines for admission to, transfer to and discharge or transfer from all hospital-based units have been developed through criteria approved by the Medical Staff,,, to assist in appropriate placement within the facility.... Each patient is reassessed at points designated in department specific policy. This includes but is not limited to reassessment: Occurring at regular intervals in the course of care (consistent with standard of care). Based on the patient's response to care. ...Assessment and reassessment data is utilized to develop the interprofessional plan of care and to revise this plan throughout the course of care: [UNIT: Emergency Dept. PERSON ASSESSING: RN & ED Physician, INITIAL TIME FRAME: Based on Intake assessment, RE-ASSESSMENT: Every 2 hrs. (hours) or change in condition]...A. Emergency Department(ED). An RN and ED provider assess all patient arriving for treatment in the Emergency Department. Patient seeking medical care are seen by the ED provider in order of priority based upon their condition or change in condition. Priority is determined by an RN based on the following criteria: Emergency Severity Index: 5 Level Triage System: Level 3-Urgent-Conditions that could potentially progress to a serious problem requiring emergency intervention. May be associated with significant discomfort or affecting ability to function at work or activities of daily living....The ED provider assesses and evaluate each patient to diagnose, treat and form a discharge plan prior to making a referral or decision regarding disposition. Reassessments are performed by RNs and physicians when: A minimum of every 2 hours for ESI level 3 or above. Level 4 and 5 patient will have vital signs reassessed every 4 hours.

Review of MR1 revealed a progress note authored by EMP14 dated January 23, 2024, at 11:10 AM with a triage assigned Emergency Severity Index (ESI) Level 3 score: (Urgent-Conditions that could potentially progress to a serious problem requiring emergency intervention. May be associated with significant discomfort or affecting ability to function at work or activities of daily living).

An interview conducted on January 26, 2024, at 1:45 PM with EMP1 confirmed MR1 (patient) was triaged as a ESI Level 3 scored patient. Further interview confirmed there was no documentation in MR1 of a reassessment by the healthcare clinical staff as required by the facility's policy for a ESI Level 3 scored patient. EMP1 stated "The medical record should have contained progress note documentation of reassessments completed by the staff as to the patient's status while in the ED external waiting room. The patient should have been given something to eat as there was a compliant by the patient (MR1) of being hungry upon arrival to the emergency department."