HospitalInspections.org

0392
Based on review of facility documents, medical record (MR), and staff interview (EMP), it was determined the facility failed to provide adequate nursing staff to administer medications on time for three of three medical records reviewed (MR11, MR12, and MR13), and failed to ensure nursing staff on the Progressive Care Unit (PCU) performed physician ordered turning and repositioning for three of three applicable medical records reviewed (MR2, MR5 and MR6).

Findings:

Review on December 2, 2020, of the facility policy, "Staffing Scheduling Procedures," last reviewed January 30, 2019, revealed "Purpose It is the policy of the following Patient Care Services (PCS) Departments of [Name of Hospital] to establish and maintain adequate staffing levels on all patient care units utilizing the scheduling process of full-time, float, part-time, weekend option, agency alternative and per diem. Scope Nursing Staff ... vi. Adjust schedule according to census 1. Six times a day, units will have new staffing requirements calculated for them automatically based on the latest census. The staffing office and/or Administrative Supervisor adjusts the schedule to meet the new needs by allocating resources as needed or adjusts staffing as needed (see guidelines below). 2. Review daily staffing worksheet regularly throughout the shift noting changing needs due to call-ins, census, and acuity of units. 3. Utilize all resources. If additional help is needed on short notice, beginning with per diems, agency alternative and regular staff for additional shifts. ..."

Review on December 2, 2020, of the facility policy, "Medication - Administration - Patient Care Services," last revised May 2020, revealed "...6. In accordance with CMS rules and regulations and best practices for patient care, the following medications are to be administered within 30 minutes of their prescribed administration time. Antibiotics Oral diabetic medications Anticonvulsants Immunosuppressive medications Pain medications ... All other medications are to be given within 1 hour of their scheduled time. ... III. Purpose: To administer medication in a safe, accurate and efficient manner ... A. Administration And Recording Of Medication Guidelines: ... 4. It is optimal to administer routine medications within 1 hour before or after the scheduled dose. Antibiotics, oral diabetics medications, anticonvulsants, immunosuppressive medications, pain medications and any medication prescribed at a frequency of every four hours or less are to be administered within 30 minutes of the prescribed administration time. ..."

A request was made for a policy or procedure for a staffing matrix. None was provided.

Interview on December 2, 2020, with EMP3 at approximately 2:00 PM, revealed the facility does not have a written staffing matrix to plan for staffing. EMP3 revealed the facility staff the hospital based on the acuity of the patients.

Review on December 2, 2020, of the CV-Telemetry Nursing Unit Assignment Sheet dated November 23, 2020, revealed three nurses were scheduled to work at 7:00 PM for a patient census of 28.

Interview on December 2, 2020, with EMP6, at approximately 1:30 PM confirmed on November 23, 2020, at 7:00 PM, three nurses were scheduled to care for 28 patients. EMP6 revealed a census of 28 patients called for 6 nurses. EMP6 revealed the three scheduled nurses refused to take the patient assignment due to patient safety. EMP6 revealed at that time administration called physicians and requested patients be transferred to other nursing units. EMP6 revealed the CV-Telemetry Nursing Unit was also the COVID-19 unit and the patient acuity were high. EMP6 confirmed there were not enough nurses to safely care for the patients.

Review on December 2, 2020, of MR11 revealed MR11 was ordered enoxaparin (an anticoagulant medication) 40 milligrams (mg) subcutaneously at 2100. There was nursing documentation MR11 received their enoxaparin at 2225 on November 23, 2020.

Interview on December 2, 2020, with EMP6, at approximately 1:35 PM confirmed MR11 received their anticoagulant medication, enoxaparin 40 mg subcutaneously late on November 23, 2020.

Review on December 2, 2020, of MR12 revealed MR12 was ordered ceftriaxone (an antibiotic) 1000 mg intravenous (IV) at 1800 on November 23, 2020. There was nursing documentation MR12 received their ceftriaxone at 0033 on November 24, 2020.

Continued review of MR12 revealed MR12 was ordered diltiazem (a cardiac medication) 30 mg by mouth at 2100 on November 23, 2020. There was nursing documentation MR12 received their diltiazem at 0034 on November 24, 2020.

Continued review of MR12 revealed MR12 was ordered docusate sodium (a stool softener) 100 mg by mouth at 2100 on November 23, 2020. There was nursing documentation MR12 received their docusate sodium at 0035 on November 24, 2020.

Continued review of MR12 revealed MR12 was ordered heparin (an anticoagulant medication) 5,000 units subcutaneously at 2200 on November 23, 2020. There was nursing documentation MR12 received their heparin at 0034 on November 24, 2020.

Interview on December 2, 2020, with EMP6, at approximately 1:45 PM confirmed MR12 received their ceftriaxone, diltiazem, docusate sodium, and heparin medications late on November 24, 2020.

Review on December 2, 2020, of MR13 revealed MR13 was ordered albuterol inhaler (a medication to treat bronchospasm) two puffs at 2000. There was nursing documentation MR13 received their albuterol inhaler at 2244 on November 23, 2020.

Continued review of MR13 revealed MR13 was ordered methylprednisolone (a steroid) 40 mg IV at 2100 on November 23, 2020. There was nursing documentation MR13 received their methylprednisolone at 2243 on November 23, 2020.

Interview on December 2, 2020, with EMP6, at approximately 2:00 PM, confirmed MR13 received their albuterol inhaler and methylprednisolone medications late on November 23, 2020.

Review on December 2, 2020, of the facility's "Patient's Rights and Responsibilities - Patient Relations" policy, last reviewed / revised August 2019 revealed "... Article II Patient Bill of Rights The Board of Directors of LVH-P [Lehigh Valley Hospital - Pocono] hereby establishes that each patient at LVH-P shall enjoy each of the following: ... 8. The right to good quality care and high professional standards that are continually maintained and reviewed. ...12. The right to expect good management techniques to be implemented within LVH-P with regards to effective use of the time of the patient, and to avoid causing the [sic] any personal discomfort. ..."

Review on December 3, 2020, of the facility's "Skin Integrity: Potential for Impairment and Impaired" policy, last approved October 2, 2019 revealed "... II. Key Points ... Prevention: ... 6. Patients who are immobile are vulnerable to having impaired skin integrity especially over bony prominences and require frequent repositioning. ..."

Review on December 3, 2020, of the facility's "Braden Scale for Predicting Pressure Score Risk 2019" revealed "... Score Interpretation: Score 15 - 18 = mild risk; Score 13 - 14 = moderate risk; Score 10 - 12 = high risk; Score [sic] less than 9 = very high risk ..."

Review on December 3, 2020, of the facility's "Patient Care Rounding - Patient Care Services" policy, last approved September 24, 2019 revealed "... II. Key Points: ... 2. Patient Rounding occurs hourly from 0600 to 2200 and every 2 hours from 2200 to 0600. ... III. Purpose: Patient Rounding is an integral part of caring for our patients. Its purpose is to establish standard work with the desired goal to increase patient satisfaction, patient safety, and patient outcomes. ... VII. Intervention / Guideline: ... 5. Clinical staff will accomplish the following items as part of the rounding process. a. Personal Needs Toileting offered and or completed. Foley catheter in proper position for drainage. ... c. Position HOB [Head Of Bed] less than or equal to [sic] 30 degrees - to reduce risk for development of pressure ulcers. Patient turned and or repositioned every 2 hours. ..."

Review of MR2 on December 3, 2020, revealed this patient was admitted to the facility on November 28, 2020, with altered mental status, an open area on the heel and was not able to reposition self. Nursing determined MR2's Braden score as 11. MR2's physician wrote an order instructing nursing staff to turn and reposition this patient very two hours.

Interview with EMP8 on December 3, 2020, at approximately 11:50 AM confirmed MR2 was admitted to the facility with altered mental status, an open area on the heel and was not able to reposition self; nursing determined MR2's Braden score as 11 and this patient's physician wrote an order instructing nursing staff to turn and reposition this patient very two hours.

Review of MR2's turning and repositioning flowsheet on December 3, 2020, revealed nursing turned and repositioned this patient at 11:55 AM on November 29, 2020, and again at 11:40 PM on November 30, 2020. There was no documentation in MR2 indicating nursing staff turned and repositioned this patient from 11:55 AM on November 29, 2020, to 11:40 PM on November 30, 2020.

Interview with EMP8 on December 3, 2020, at approximately 11:50 AM confirmed MR2's turning and repositioning flowsheets for November 29 and 30, 2020, indicted nursing staff turned and repositioned this patient at 11:55 AM on November 29, 2020, and again at 11:40 PM on November 30, 2020. EMP8 confirmed there was no documentation in MR2 indicating nursing staff turned and repositioned this patient from 11:55 AM on November 29, 2020, to 11:40 PM on November 30, 2020. EMP8 confirmed MR2 was not turned and repositioned every two hours as ordered by this patient's physician.

Review of MR5 on December 3, 2020, revealed this patient was admitted to the facility on December 1, 2020, with diabetic cardiomyopathy (inability of the heart to circulate blood through the body effectively), was bedfast and was not able to reposition self. Nursing determined MR5's Braden score as 9. MR5's physician wrote an order instructing nursing staff to turn and reposition this patient very two hours.

Interview with EMP8 on December 2, 2020, at approximately 11:55 AM confirmed MR5 was admitted to the facility with diabetic cardiomyopathy, was bedfast and was not able to reposition self; nursing determined MR5's Braden score as 9 and this patient's physician wrote an order instructing nursing staff to turn and reposition this patient very two hours.

Review of MR5's turning and repositioning flowsheet on December 3, 2020, revealed nursing turned and repositioned this patient at 11:11 AM on December 2, 2020, and again at 11:04 PM on December 2, 2020. There was no documentation in MR5 indicating nursing staff turned and repositioned this patient from 11:11 AM on December 2, 2020, to 11:04 PM on December 2, 2020.

Interview with EMP8 on December 3, 2020, at approximately 11:55 AM confirmed MR5's turning and repositioning flowsheet for December 2, 2020 indicated nursing staff turned and repositioned this patient at 11:11 AM and again at 11:04 PM. EMP8 confirmed there was no documentation in MR5 indicating nursing staff turned and repositioned this patient from 11:11 AM to 11:04 PM December 2, 2020. EMP8 confirmed MR5 was not turned and repositioned every two hours as ordered by this patient's physician.

Review of MR6 on December 3, 2020, revealed this patient was admitted to the facility on November 27, 2020, following a STEMI (a full-blown heart attack caused by a complete blockage of a heart artery), was incontinent, bedfast and was not able to reposition self. Nursing determined MR6's Braden score an 11. MR6's physician wrote an order instructing nursing staff to turn and reposition this patient very two hours.

Interview with EMP8 on December 3, 2020, at approximately 12:05 PM confirmed MR6 was admitted to the facility following a STEMI, was incontinent, bedfast and was not able to reposition self; nursing determined MR6's Braden score an 11 and this patient's physician wrote an order instructing nursing staff to turn and reposition this patient very two hours.
Review of MR6's turning and repositioning flowsheets on December 3, 2020, revealed nursing turned and repositioned on:
November 27, 2020, at 9:56 PM;
November 28, 2020, at 8:00 AM;
November 28, 2020, at 7:55 PM;
November 29, 2020, at 7:50 PM;
November 30, 2020, at 8:00 AM;
November 30, 2020, at 10:40 PM;
December 1, 2020, at 5:25 AM;
December 1, 2020, at 8:00 AM;
December 1, 2020, at 2:00 PM;
December 1, 2020, at 5:46 PM;
December 1, 2020, at 7:40 PM; and,
December 2, 2020, at 10:00 AM.

There was no documentation in MR6 indicating nursing staff turned and repositioned this patient every two hours from 9:56 PM on November 27, 2020, to 10:00 AM on December 2, 2020.

Interview with EMP8 on December 3, 2020, at approximately 12:05 PM confirmed MR6's turning and repositioning flowsheets from 9:56 PM on November 27, 2020, to 10:00 AM on December 2, 2020. EMP8 confirmed there was no documentation in MR6 indicating nursing staff turned and repositioned this patient every two hours from 9:56 PM on November 27, 2020, to 10:00 AM on December 2, 2020. EMP8 confirmed MR6 was not turned and repositioned every two hours as ordered by this patient's physician.

Based on the systemic non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

482.55(a)(2) Tag A-1103
Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to monitor a patient's elevated blood pressure while in the Emergency Department (ED) for one of one medical record reviewed MR3; the facility failed to provide food to a patient in the ED for five of five applicable medical records reviewed (MR3, MR4, MR5, MR6 and MR8) and the facility failed to ensure personal hygiene was offered, provided or completed while a patient in the ED for three of five applicable medical records reviewed (MR5, MR6 and MR8).

482.55(b) Tag A-1110
Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to provide adequate staff in the Emergency Department for five of seven assignment sheets reviewed.

482. 55(b)(2) Tag A-1112
Based on review of facility documents, medical record (MR), and staff interview (EMP), it was determined the facility failed to provide a dedicated Trauma Certified Registered Nurse for five of seven assignment sheets reviewed and failed to provide a Triage Registered Nurse for seven of seven assignment sheets reviewed.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to monitor a patient's elevated blood pressure while in the Emergency Department (ED) for one of one medical record reviewed MR3; the facility failed to provide food to patients in the ED for five of five applicable medical records reviewed (MR3, MR4, MR5, MR6 and MR8) and the facility failed to ensure personal hygiene was offered, provided or completed to patients in the ED for three of five applicable medical records reviewed (MR5, MR6 and MR8).

Findings include:

Review on December 2, 2020, of the facility's "Documentation of Vital Signs in the Emergency Department - Emergency Medicine" policy, last approved October 9, 2019 revealed "... II. Policy: To ensure and provide a standard of care throughout the Department of Emergency Medicine for documentation of vital signs for all patients presenting to the emergency department. ... IV. Procedure: ... 2. It is recommended that vital signs will be taken and documented every 2 hours on all ESI (Emergency Severity Index) 2 and every 4 hours on ESI 3 unless otherwise ordered by the ED physician. ..."

Review on December 2, 2020, of the facility's "Patient's Rights and Responsibilities - Patient Relations" policy, last reviewed / revised August 2019 revealed "... Article II Patient Bill of Rights The Board of Directors of LVH-P [Lehigh Valley Hospital - Pocono] hereby establishes that each patient at LVH-P shall enjoy each of the following: ... 8. The right to good quality care and high professional standards that are continually maintained and reviewed. ..."

Review on December 3, 2020, of the facility's "Emergency Department (ED) Scope of Patient Care Services" policy, no review date, revealed IV. Department Goals and Objectives: The Emergency Department is committed to providing comprehensive and efficient quality care to the patients of the community ..."

A request was made of EMP2 on December 3, 2020, for the facility's policy, procedure, guideline or protocol Emergency Department (ED) nursing staff would follow regarding ensuring ED patients were provided food and personal hygiene while waiting for an inpatient bed. None was provided.

1. Review of MR3 on December 2, 2020, revealed this patient was admitted to the Emergency Department (ED) on December 1, 2020, with complaint of Congestive Heart Failure (CHF - a chronic condition that affects the pumping of the heart muscle) and an elevated blood pressure. Nursing determined MR3's ESI level as 2.

Review on December 2, 2020 of MR3's vital sign sheet revealed nursing recorded MR3's blood pressure as 148/99 mm Hg (millimeters of mercury) at 1:54 PM. There was a red explanation mark following this blood pressure. Nursing recorded MR3's next blood pressure at 7:35 PM as 148/94 mm Hg followed by a red explanation mark. There was no documentation in MR3 indicating nursing staff monitored this patient's elevated blood pressure from 1:54 PM to 7:35 PM on December 1, 2020.

Interview with EMP8 on December 2, 2020, at approximately 11:45 AM revealed the red explanation mark following this blood pressure indicated an abnormal reading and required monitoring. EMP8 confirmed there was no documentation in MR3 indicating nursing staff monitored this patient's elevated blood pressure.

2. Review of MR3 on December 3, 2020, revealed this patient was admitted to the ED for evaluation and treatment of Congestive Heart Failure (CHF - a chronic condition that affects the pumping of the heart muscle) on December 1, 2020 at 2:53 PM and was transferred to the Progressive Care Unit (PCU) on December 2, 2020 at 7:27 AM. There was no documentation in MR3 indicating nursing staff provided this patient with food while in the ED.

Interview with EMP8 on December 3, 2020, at the approximately 1:00 PM confirmed MR3 was admitted to the ED on December 1, 2020 at 2:53 PM and was transferred to PCU on December 2, 2020 at 7:27 AM and there was no documentation in MR3 indicating nursing staff provided this patient with food while in the ED. EMP8 revealed there was no physician order in MR3 instructing nursing staff to maintain this patient as NPO (nothing by mouth) or that this patient was ordered any dietary restrictions.

Review of MR4 on December 3, 2020, revealed this patient was admitted to the ED for evaluation and treatment of CHF and Heart Failure (HF - a condition which the heart muscle is unable to pump enough blood to meet the body's needs for blood and oxygen) on December 1, 2020 at 6:06 PM and was transferred to PCU on December 2, 2020 at 8:00 AM. There was no documentation in MR4 indicating nursing staff provided this patient with food while in the ED.

Interview with EMP8 on December 3, 2020, at the approximately 1:15 PM confirmed MR4 was admitted to the ED on December 1, 2020 at 2:53 PM and was transferred to PCU on December 2, 2020 at 7:27 AM and there was no documentation in MR4 indicating nursing staff provided this patient with food while in the ED. EMP8 revealed there was no physician order in MR4 instructing nursing staff to maintain this patient as NPO or that this patient was ordered any dietary restrictions.

Review of MR5 on December 3, 2020, revealed this patient was admitted to the ED for evaluation and treatment of diabetic cardiomyopathy (inability of the heart to circulate blood through the body effectively) on December 1, 2020 at 5:15 PM and was transferred to PCU on December 2, 2020 at 10:28 AM. There was no documentation in MR5 indicating nursing staff provided this patient with food while in the ED.

Interview with EMP8 on December 3, 2020, at approximately 1:30 PM confirmed MR5 was admitted to the ED on December 1, 2020 at 5:15 PM and was transferred to PCU on December 2, 2020 at 10:28 AM and there was no documentation in MR5 indicating nursing staff provided this patient with food while in the ED. EMP8 revealed there was no physician order in MR5 instructing nursing staff to maintain this patient as NPO or that this patient was ordered any dietary restrictions.

Review of MR6 on December 3, 2020, revealed this patient was admitted to the ED following a STEMI (a full-blown heart attack caused by a complete blockage of a heart artery) on November 27, 2020 at 11:13 AM and was transferred to PCU on November 27, 2020 at 8:56 PM. There was no documentation in MR6 indicating nursing staff provided this patient with food while in the ED.

Interview with EMP8 on December 3, 2020, at approximately 1:40 PM confirmed MR6 was admitted to the ED on November 27, 2020 at 11:13 AM and was transferred to PCU on November 27, 2020 at 8:56 PM and there was no documentation in MR6 indicating nursing staff provided this patient with food while in the ED. EMP8 revealed there was no physician order in MR6 instructing nursing staff to maintain this patient as NPO or that this patient was ordered any dietary restrictions.

Review of MR8 on December 3, 2020, revealed this patient was admitted to the ED for evaluation and treatment of a diabetic foot infection on November 23, 2020 at 4:37 PM and was transferred to PCU on November 24, 2020 at 4:49 AM. There was no documentation in MR8 indicating nursing staff provided this patient with food while in the ED.

Interview with EMP8 on December 3, 2020, at approximately 1:45 PM confirmed MR8 was admitted to the ED on November 23, 2020 at 4:37 PM and was transferred to PCU on November 24, 2020 at 4:49 AM and there was no documentation in MR8 indicating nursing staff provided this patient with food while in the ED. EMP8 revealed there was no physician order in MR8 instructing nursing staff to maintain this patient as NPO or that this patient was ordered any dietary restrictions.

3. Review of MR5 on December 3, 2020, revealed this patient was admitted to the ED on December 1, 2020 at 5:15 PM and was transferred to PCU on December 2, 2020 at 10:28 AM. There was no documentation in MR5 indicating nursing staff offered, provided or completed personal hygiene on this patient while in the ED.

Interview with EMP8 on December 3, 2020, at approximately 1:30 PM confirmed MR5 was admitted to the ED on December 1, 2020 at 5:15 PM and was transferred to PCU on December 2, 2020 at 10:28 AM and there was no documentation in MR5 indicating nursing staff offered, provided or completed personal hygiene on this patient while in the ED.

Review of MR6 on December 3, 2020, revealed this patient was admitted to the ED on November 27, 2020 at 11:13 AM and was transferred to PCU on November 27, 2020 at 8:56 PM. There was no documentation in MR6 indicating nursing staff offered, provided or completed personal hygiene on this patient while in the ED.

Interview with EMP8 on December 3, 2020, at approximately 1:40 PM confirmed MR6 was admitted to the ED on November 27, 2020 at 11:13 AM and was transferred to PCU on November 27, 2020 at 8:56 PM and there was no documentation in MR6 indicating nursing staff offered, provided or completed personal hygiene on this patient while in the ED.

Review of MR8 on December 3, 2020, revealed this patient was admitted to the ED on November 23, 2020 at 4:37 PM and was transferred to PCU on November 24, 2020 at 4:49 AM. There was no documentation in MR8 indicating nursing staff offered, provided or completed personal hygiene on this patient while in the ED.

Interview with EMP8 on December 3, 2020, at approximately 1:45 PM confirmed MR8 was admitted to the ED on November 23, 2020 at 4:37 PM and was transferred to PCU on November 24, 2020 at 4:49 AM and there was no documentation in MR8 indicating nursing staff offered, provided or completed personal hygiene on this patient while in the ED.

Interview with EMP19 on December 2, 2020, at approximately 9:20 AM revealed there are many ED holds due to staffing on inpatient units. EMP19 revealed there are not enough ED staff to adequately care for the patients waiting for an admission bed. EMP19 revealed patients are often not fed or toileted properly due to the holds in the ED and staffing.

Interview with EMP20 on December 2, 2020, at approximately 9:15 AM revealed the patients in the ED often are not bathed, toileted, or fed properly. EMP20 revealed there were not enough staff within the ED to provide the patients with adequate nursing care.

Cross reference:
482.55(b) Emergency Services Personnel
482.55(b)(2) Qualified Emergency Services Personnel

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to provide adequate staff in the Emergency Department for five of seven assignment sheets reviewed.

Findings:

Review on December 3, 2020, of the facility policy, "Emergency Department (ED) Scope of Patient Care Services, no date of last review, revealed "...I. Scope of Service a. Types of Patients Served: To provide a hospital plan for patients arriving in the Emergency Department with emergent needs that require immediate intervention and treatment. These services are available to the ED 24/7 and provide direct care to patients. b. Definitions: ESI: Emergency Severity Index: "is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patient into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs (ESI, 2013)." c. Services, Treatments, Procedures, and Activities Performed: 1. Methods to assess and meet care needs are based on assessment in the triage and/or treatment area depending on the ESI assigned to the patient. ... d. Areas/Sites Where Services are Provided: Ground Floor, D-Wing consisting of 54 rooms. ... IV. Department Goals and Objectives: The Emergency Department is committed to providing comprehensive and efficient quality care to the patients of the community. ..."

Review on December 2, 2020, of the facility policy, "Staffing Scheduling Procedures," last reviewed January 30, 2019, revealed "Purpose It is the policy of the following Patient Care Services (PCS) Departments of [Name of Hospital] to establish and maintain adequate staffing levels on all patient care units utilizing the scheduling process of full-time, float, part-time, weekend option, agency alternative and per diem. Scope Nursing Staff ... vi. Adjust schedule according to census 1. Six times a day, units will have new staffing requirements calculated for them automatically based on the latest census. The staffing office and/or Administrative Supervisor adjusts the schedule to meet the new needs by allocating resources as needed or adjusts staffing as needed (see guidelines below). 2. Review daily staffing worksheet regularly throughout the shift noting changing needs due to call-ins, census, and acuity of units. 3. Utilize all resources. If additional help is needed on short notice, beginning with per diems, agency alternative and regular staff for additional shifts. ..."

A request was made for a policy or procedure for a staffing matrix. None was provided.

Interview on December 2, 2020, with EMP3 at approximately 2:00 PM, revealed the facility does not have a written staffing matrix to plan for staffing. EMP3 revealed the facility staffs the hospital based on the acuity of the patients.

Interview on December 2, 2020, with EMP4 at approximately 9:30 AM, confirmed the facility ED contains 54 patient rooms. EMP4 revealed most rooms are not utilized due to insufficient nurses within the ED.

Review on December 4, 2020, of the ED Data Summary Table dated November 24, 2020, revealed 100 patients presented to the ED. There was documentation 15 patients left the ED without being seen.

Review on December 4, 2020, of the ED Assignment Sheet dated November 24, 2020, revealed there were four Registered Nurses (RNs) scheduled at 7:00 AM. There was documentation the ED Director was assigned Charge Nurse duties and the ED Supervisor was assigned the Trauma Nurse duties.

Interview on December 4, 2020, with EMP4 revealed on November 24, 2020, at 7:00 AM, ED staffing called for seven RNs. EMP4 explained the ED Director and Supervisor took staffing assignments in order to have six RNs working within the ED. EMP4 confirmed the ED did not meet its staffing requirements.

Review on December 4, 2020, of the ED Assignment Sheet dated November 24, 2020, revealed there were nine RNs scheduled at 3:00 PM. There was documentation the ED supervisor was assigned the Charge Nurse duties.

Interview on December 4, 2020, of with EMP4 revealed on November 24, 2020, at 3:00 PM staffing called for 13 nurses. EMP4 explained the ED supervisor was assigned to Charge Nurse duties in order to have 10 nurses. EMP4 confirmed the ED did not meet its staffing requirements.

Review on December 4, 2020, of the ED Assignment Sheet dated November 24, 2020, revealed there were six RNs scheduled for 11:00 PM. There was documentation the ED Director was assigned the Charge Nurse duties.

Interview on December 4, 2020, with EMP4 at approximately 10:45 AM, revealed on November 24, 2020, at 11:00 PM staffing called for eight RNs. EMP4 explained the ED Director was assigned to Charge Nurse duties in order to have seven nurses. EMP4 confirmed the ED did not meet its staffing requirements.

Review on December 2, 2020, of the ED Assignment Sheet dated December 2, 2020, revealed there were four RNs scheduled at 7:00 AM. There was documentation the ED Director was assigned the Charge Nurse duties and the ED Supervisor was assigned the Trauma Nurse duties.

Interview on December 2, 2020, with EMP4 at approximately 9:30 AM revealed on December 2, 2020, at 7:00 AM ED staffing called for seven RNs. EMP4 explained the ED Director and Supervisor took staffing assignments in order to have six RNs working within the ED. EMP4 confirmed the ED did not meet its staffing requirements.

Review on December 2, 2020, of the ED Assignment sheet dated November 1, 2020, revealed there were four RNs scheduled at 7:00 AM, nine RNs scheduled at 3:00 PM, and five RNs scheduled at 11:00 PM.

Interview on December 2, 2020, with EMP4 at approximately 9:35 AM revealed on November 1, 2020, at 7:00 AM ED staffing called for 7 RNs, 13 RNs at 3:00 PM, and eight RNs at 11:00 PM. EMP4 confirmed the ED did not meet its staffing requirements.

Review on December 2, 2020, of the ED Assignment Sheet dated November 2, 2020, revealed there were six RNs scheduled at 7:00 AM, 12 RNs scheduled at 3:00 PM, and six RNs scheduled at 11:00 PM.

Interview on December 2, 2020, with EMP4 at approximately 9:40 AM, revealed on November 2, 2020 at 7:00 AM ED staffing called for seven RNs, 13 RNs at 3:00 PM, and eight RNs at 11:00 PM. EMP4 confirmed the ED did not meet its staffing requirements.

Review on December 2, 2020, of the ED Assignment Sheet dated November 13, 2020, revealed there were five RNs scheduled at 7:00 AM, 10 RNs scheduled at 3:00 PM, and six RNs scheduled at 11:00 PM.

Interview on December 2, 2020, with EMP4 at approximately 9:45 AM, revealed on November 13, 2020 at 7:00 AM ED staffing called for seven RNs, 13 RNs at 3:00 PM, and eight RNs at 11:00 PM. EMP4 confirmed the ED did not meet its staffing requirements.

Review on December 2, 2020, of the ED Assignment Sheet dated November 14, 2020, revealed there were four RNs scheduled at 7:00 AM, 8 RNs scheduled at 3:00 PM, and six RNs scheduled at 11:00 PM.

Interview on December 2, 2020, with EMP4 at approximately 9:50 AM, revealed on November 14, 2020 at 7:00 AM ED staffing called for seven RNs, 13 RNs at 3:00 PM, and eight RNs at 11:00 PM. EMP4 confirmed the ED did not meet its staffing requirements.

Interview on December 4, 2020, with EMP4 at approximately 10:15 AM, confirmed on November 24, 2020, 100 patients presented to the facility ED. EMP4 confirmed 15 patients left the ED without being seen. EMP 4 confirmed the facility goal of patients leaving the ED without being seen is two percent. EMP4 confirmed on November 24, 2020, 15 percent of the facility's ED patients left without being seen. EMP4 confirmed the facility did not meet their goal and are not meeting patient satisfaction. EMP4 confirmed there were not enough nurses scheduled in the ED on November 1, 2, 13, 14, and 24, 2020, for the volume of ED patients.

Interview on December 4, 2020, with EMP2, at approximately 11:10 AM, confirmed the ED staffing is not optimal for patient care.

Interview on December 2, 2020, with EMP3, at approximately 2:00 PM, revealed the facility does not utilize Diversion. EMP3 explained the facility procedure is to accept all patients, screen and stabilize, and transfer to a network facility as necessary.

Cross reference:
482.55(a)(2) Integration of Emergency Services

Based on review of facility documents, medical record (MR), and staff interview (EMP), it was determined the facility failed to provide a dedicated Trauma Certified Registered Nurse for five of seven assignment sheets reviewed and failed to provide a Triage Registered Nurse for seven of seven assignment sheets reviewed.

Findings:

Review on December 3, 2020, of the facility policy, "Responsibilities of the Trauma Nurse," no date of last review, revealed "Guidelines 1. Procedure /Responsibility /Action a. Trauma Nurse: i. Trauma nurse must have at least 2 years of experience as an emergency department nurse. ii. Trauma nurse must be proficient in all areas of the emergency department, including acute, sub-acute, minor care, and triage. iii. The Trauma Nurse is required to be TNC [Trauma Nurse Certification] certified within 1 year. ... vii. Maintain compliance with the Trauma Foundation and JCACHO standards for care and documentation. ... ix. Circulate through the department to evaluate Trauma patients when not involved in a Trauma Alert. Assist with Trauma patients throughout the department if available. The Trauma nurse will act as a mentor to their peers in order to assure Trauma patient evaluation and care is of the highest quality. x. The Trauma nurse will act as the bedside nurse in all alerts and will be in charge of the room during the alerts. Directly coordinates the activity of the Trauma team, in collaboration with the Trauma attending. ..."

Review on December 2, 2020, of the facility's Trauma policy, "Standards of Accreditation," no date of last review, revealed "Standard 16 Emergency Department 1. Adequate Emergency Department facilities and personnel will be available to simultaneously care for two or more major uni-system or multi-system trauma patients. A. Back-up areas must be identified and immediately available. 2. It is the responsibility of the institution to ensure that the Emergency Department is staffed by registered nurses who have demonstrated special capabilities through commitment, continuing education and experience. A. The Emergency Department will have a staffing plan that reflects the trending, severity of injury, arrival of multiple trauma patients, and staffing/skill mix required to ensure the appropriate care of trauma patients. B. A minimum of two (2) RN's who are capable to actively function in trauma resuscitations must be present in the Emergency Department at all times. i. Level III: One (1) RN at all times who is capable to actively function in trauma resuscitations must be present in the Emergency Department at all times. ..."

Review on December 3, 2020, of the facility policy, "Arrival Of The Trauma Patient To The Emergency Department," no date of last review, "Purpose: In order to expedite the care of trauma patients, the patient will be evaluated upon arrival to the department by the Charge nurse or Triage nurse. Using the 'Protocol for Trauma Triage' the Charge Nurse or Triage Nurse will determine if a patient is categorized as a trauma alert or consult. Guidelines 1. Trauma Alert: A trauma alert is called when a patient presents to the ED and meets the criteria of the Trauma Triage Guidelines. 2. Trauma Consult (Level 2 or 3 Trauma Patient) a. The trauma consult is a level 2 or 3 Trauma patients that do not meet the criteria for a trauma alert but because of a high suspicion for injury, certain identity markers, or comorbidities or trauma mechanism would expedite the care of the patient. 3. Arrival Trauma Patient a. Upon arrival to The ED department the trauma patient will be evaluated. The ED patient will arrive either by ambulance or will walk into the department. The following will occur. i. Ambulance Patients: 1. The Charge Nurse will evaluate all ambulance patients upon arrival to the ED department according to the Trauma Triage guidelines. 2. It will be determined by the Charge Nurse if the patient falls in the category of trauma alert or consult (Level 2 or 3 trauma patient.) ii. Walk in Patients that arrive at the greeter desk: 1. This patient will be questioned by the greeter according to the Trauma Triage Guidelines. 2. The greeter will notify the triage nurse immediately if the patient falls into the alert or mechanism category. 3. The Triage Nurse will access the patient and notify the charge nurse immediately for a bed if the patient meets criteria. ..."

Review on December 2, 2020, of the facility's Trauma Accreditation revealed the facility was a Level III Trauma Center.

Interview on December 2, 2020, with EMP2 at approximately 10:00 AM, confirmed the facility was a Level III Trauma Center.

Review on December 2, 2020, of the Emergency Department (ED) Assignment Sheet dated November 1, 2020, revealed there was no dedicated assigned Trauma Registered Nurse from 7:00 AM to 9:00 AM and from 11:00 PM until November 2, 2020 at 7:00 AM.

Interview on December 2, 2020, with EMP4 at approximately 9:30 AM, confirmed there was no dedicated assigned Trauma Registered Nurse on November 1, 2020 from 7:00 AM to 9:00 AM and from 11:00 PM until November 2, 2020 at 7:00 AM.

Review on December 2, 2020, of the ED Assignment Sheet dated November 3, 2020, revealed there was no dedicated assigned Trauma Registered Nurse from 3:00 AM to 7:00 AM.

Interview on December 2, 2020, with EMP4 at approximately 9:35 AM, confirmed there was no dedicated assigned Trauma Registered Nurse on November 3, 2020 from 3:00 AM to 7:00 AM.

Review on December 2, 2020, of the ED Assignment Sheet dated November 13, 2020, revealed there was no dedicated assigned Trauma Registered Nurse from 11:00 PM until November 14, 2020 at 9:00 AM.

Interview on December 2, 2020, with EMP4 at approximately 9:40 AM, confirmed there was no dedicated assigned Trauma Registered Nurse on November 13, 2020 from 11:00 PM until November 14, 2020 at 9:00 AM.

Review on December 2, 2020, of the ED Assignment Sheet dated November 25, 2020, revealed there was no dedicated assigned Trauma Registered Nurse from 3:00 AM to 7:00 AM.

Interview on December 2, 2020, with EMP4 at approximately 9:45 AM, confirmed there was no dedicated assigned Trauma Registered Nurse on November 25, 2020 from 3:00 AM to 7:00 AM.

Review on December 2, 2020, of MR9 revealed MR9 arrived at the ED via EMS on November 2, 2020, at 1:45 AM. There was documentation a Trauma Alert was activated for MR9 at 1:45 AM. There was documentation MR9 was involved in a head on motor vehicle collision and sustained orthopedic injuries. There was documentation MR9 was ordered to be transferred to tertiary care facility and was transferred on November 2, 2020, at 4:45 AM. There was documentation PF1 cared for the patient from 3:00 AM to 4:45 AM.

Review on December 2, 2020, of PF1 revealed PF1 was not trauma certified and did not have two years of Emergency Department experience. There was documentation PF1 was a Registered Nurse for approximately 11 months.

Interview on December 2, 2020, with EMP7, at approximately 1:00 PM, confirmed PF1 was not a trauma certified registered nurse and did not meet the facility's requirements of Trauma Nurse.

Review on December 4, 2020, of the facility policy, "Triage System For The Emergency Department - Emergency Medicine," last reviewed January 21, 2020, revealed "... II. Key Points: 1. Triage identifies who cannot wait to be seen and allows the ED to route patients as expeditiously as possible for definitive care to the appropriate emergency department area according to their priority. 2. Triage collaborates with the charge nurse regarding bed availability, ESI, and severity of patients in the waiting area. 3. Triage is to be considered a priority function. III. Purpose: To evaluate patients in the shortest possible period of time, to identify those illnesses or injuries requiring immediate emergency care. Additionally, the triage system will address the necessary first aid for patient seeking emergency care and will assist with patient/family understanding of the treatment environment. IV. Definitions: ... Triage - The process of sorting patients by severity of illness or injury and assigning a rating to prioritize treatment. ...VII. Intervention / Guideline: Guidelines: 1. Patients entering the waiting area will be assessed to determine ESI level. 2. The triage nurse initiates the ED Nursing Flow Sheet and assigns triage status ... 3. Triage when appropriate, initiates emergency nurse guidelines and first aid measures (i.e. ice packs, dressings, x-rays, simple splints, wheel chair for patients with lower limb problems, etc.) ... 5. An ESI of 4 or 5 can be accompanied by an ED intake personnel or volunteer or be called into the treatment area by the assigned nurse. All patient assigned an ESI of 2 will be accompanied by an appropriately trained staff member to a treatment area. When it becomes necessary for the triage staff member to accompany a patient to a treatment area, the responsibility for the patient should be assumed by the assigned nurse or charge nurse as soon as possible so that the triage staff member may return to the triage area. 6. The triage area will be continually monitored to provide assistance as necessary, coordinate information and communicate information to families. ... 13. Triage will be performed 24/7. 14. Triage is to be considered a priority staffing function. The assigned triage staff reports to the emergency department charge nurse. 15. The charge nurse will have the responsibility to assign triage duty, offer triage back up as needed, and make the decision to adjust triage staffing temporarily should a staffing emergency arise. 16. Triage collaborates with the charge nurse regarding bed availability, ESI, and severity of patients. ..."

Review on December 4, 2020, of the facility document, "TeleTriage RN Standard Work Document," last revised February 16, 2020, revealed "Goal: The goal of the TeleTriage process is to facilitate the completion of triage for patients presenting to the ED. The TeleTriage RN provides assistance to onsite RN staff to ensure that patients are fully triaged in a timely manner and, when applicable, initiate RN protocols. Important: The TeleTriage RN will only be deployed as each site identifies the need for the resource. Baseline triggers indicating a need for TeleTriage assistance (by site) are listed below: ... ED Pocono 8 or more patients not triaged ..."

Review on December 4, 2020, of the facility document, "Pocono ED TeleTriage Talking Points," last revised February 15, 2020, revealed "TeleTriage service starts at 9:30 AM and goes until 10:00 PM. They are assisting 4 other sites (besides Pocono) with their triage needs. Around 9:30 the facility will receive a call from the tele triage RN to let the site know they are ready, They will request a test of equipment and ensure the iPAD is ready for daily operations ... When to call the TeleTriage RN: When the help is needed. The Pocono ED will use 8 pts in the WR w/ no anticipate movement as a TeleTriage start trigger. What the TeleTriage RN is NOT to do: Triage every single person. This expectation is difficult to meet especially as 5 sites are supported for this process. Kids less than 3, no other language besides Spanish (especially after 4 pm), or if a live Spanish interpreter is not available, psych evaluation, LOC. ..."

Interview on December 4, 2020, with EMP4 at approximately 10:00 AM, revealed the TeleTriage service is a process to decompress the ED waiting room. EMP4 confirmed the TeleTriage service is the not meant to be the facility's primary triage process. EMP4 confirmed the ED doesn't have enough staff to assign an onsite triage nurse.

Interview on December 2, 2020, with EMP5 at approximately 10:30 AM, confirmed the facility utilizes the TeleTriage service as its primary triage process. EMP5 revealed it is unsafe to leave patients in the waiting room without a triage nurse present.

Review on December 2, 2020, of the ED Assignment Sheet dated November 1, 2020, revealed there was no assigned Triage Nurse from 7:00 AM until November 2, 2020, at 11:00 AM.

Interview on December 2, 2020, with EMP4 at approximately 9:30 AM, confirmed there no assigned Triage Nurse on November 1, 2020 from 7:00 AM until November 2, 2020, at 11:00 AM.

Review on December 2, 2020, of the ED Assignment Sheet dated November 2, 2020, revealed there was no assigned Triage Nurse from 7:00 PM until November 3, 2020, at 7:00 AM.

Interview on December 2, 2020, with EMP4 at approximately 9:35 AM, confirmed there no assigned Triage Nurse on November 2, 2020 from 7:00 PM until November 3, 2020, at 7:00 AM.

Review on December 2, 2020, of the ED Assignment Sheet dated November 13, 2020, revealed there was no assigned Triage Nurse from 7:00 AM until November 15, 2020, at 7:00 AM.

Interview on December 2, 2020, with EMP4 at approximately 9:40 AM, confirmed there no assigned Triage Nurse on November 13, 2020 from 7:00 AM until November 15, 2020, at 7:00 AM.

Review on December 2, 2020, of the ED Assignment Sheet dated November 17, 2020, revealed there was no assigned Triage Nurse from 7:00 AM until 7:00 PM and from 9:00 PM until November 18, 2020, at 7:00 AM.

Interview on December 2, 2020, with EMP4 at approximately 9:45 AM, confirmed there no assigned Triage Nurse on November 17, 2020 from 7:00 AM until 7:00 PM and from 9:00 PM until November 18, 2020, at 7:00 AM.

Review on December 2, 2020, of the ED Assignment Sheet dated November 24, 2020, revealed there was no assigned Triage Nurse from 7:00 AM until November 25, 2020 at 7:00 AM

Interview on December 2, 2020, with EMP4 at approximately 9:45 AM, confirmed there no assigned Triage Nurse on November 24, 2020 from 7:00 AM until November 25, 2020 at 7:00 AM.

Review on December 3, 2020, of the facility incident report dated November 24, 2020, revealed an incident report which stated Tele-Triage services were offline from 17:30 to 18:00. MR10 was not triaged and at 1900 patient became unresponsive in ED waiting area. A trauma alert was called at 1900.

Review on December 4, 2020, of MR10, revealed MR10 walked into the ED on November 24, 2020 at 18:26. There was documentation MR10's chief complaint was he fell off a bike. There was no documentation MR10 was triaged. There was documentation MR10 was roomed at 19:11. There was documentation MR10 was triaged at 19:23 after the patient was roomed by the assigned nurse. There was documentation MR10 fell off a bicycle headfirst and was assigned Acuity 1 and a Trauma Alert.

Continued review of MR10 revealed physician documentation MR10 was a 21-year-old male with a complaint of falling off his bike and hitting his head. There was documentation MR10 had history of seizures and was not on seizure medication. There was also physician documentation MR10 was in the waiting room for approximately 45 minutes and the patient syncopized. There was documentation MR10 had an EKG completed and was within normal limits. There was documentation MR10's right temporal laceration was repaired. There was documentation MR10 had labs drawn, x-ray of left knee, and CT scan. There was documentation at 21:25 MR10 was advised he should be admitted for further evaluation. MR10 refused admission and signed out against medical advice.

Interview on December 3, 2020, with EMP5, at approximately 10:00 AM, confirmed an incident report was completed on November 24, 2020. EMP5 confirmed there was no Triage Nurse on November 24, 2020. EMP5 confirmed Tele-Triage service was not available November 24, 2020 from 17:30 to 18:00. EMP5 revealed this resulted in a backup in the waiting area. EMP5 confirmed MR10 arrived at the ED on November 24, 2020 at 18:26 and was not triaged. EMP5 confirmed MR10 became unresponsive in the waiting area and was brought back to a room and a Trauma Alert was called. EMP5 revealed without a Triage Nurse there are no eyes in the waiting area and patients may not get a proper assessment. EMP5 revealed there was not enough staff to triage and take care of the patients on November 24, 2020.

Cross reference:
482.55(a)(2) Integration of Emergency Services