HospitalInspections.org

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

A. ensure patient received care in a safe and sanitary environment in 1 of 1 Emergency Department (ED). They failed to ensure the hallways and egress were kept free and unblocked which would allow easy access in an area dealing with emergency care.
Refer to tag A0144 for additional information.

Based on observation, interview and records review, the facility failed to ensure patient rights to receive care in a safe and sanitary environment in 1 of 1 Emergency Department (ED).

This deficient practice had the likelihood to cause harm to all patients presenting to the ED.

Findings include:

During an observation of the ED on 02/18/2015 after 10:05 a.m. the following was found:

Trauma room (in front of the nursing station)
Underneath the bed mattress was an open packet which contained a Yaukauers suctioning catheter. Tape was on the floor outlining the area for the trash bins and crash carts. The tape was peeling up and was soiled with dirt and debris. The pedals to the trash and biohazard bin had a buildup of dirt. The crash cart in the room had clean supplies and the defibrillator stored on top of it and all items were covered in dust. The ambu bag was stored in an open plastic bag exposing it to spills and dust. The suction canister and tubing attached were covered with a layer of dust. The wheels to the crash cart were rusted. A ceiling light cover was full of dead bugs as you enter the room.

The hallways were cluttered with linen carts, supply carts, beds with and without patients, wheelchairs, scales and family members sitting in chairs. One unidentified patient was sitting on a bed in the hallway and had on a mask.

At 10:25 a.m., the bed in Room #9 had soiled linen still on the bed. Staff #1 reported the last patient left the room at 10:02 a.m..

At 10:30 a.m., the bed in Room #7 had soiled linen still on the bed. Staff #1 reported the last patient left the room at 10:17 a.m.. Sections of the top portion of the tan colored wall covering was missing, exposing the white drywall underneath. The foot pedals on the patient bed had a buildup of dirt. The mattress had an old opsite dressing stuck to it that had to be peeled off. The outside of the paper towel dispenser was covered with old tape. The inside area where you pulled the paper towels out had a build-up of substance in the crevices.

The main public bathroom, on the same hallway (as Room #7), had wall tile behind and on side of the toilet with soiled grout. The sink faucet and handles were soiled with a build-up and the piping underneath the sink was missing the white PVC covering. The paper towel dispenser on the inside area, where you pulled the paper towels out, had a build-up of substance in the crevices.

At 10:52 a.m., Room #6 was identified as being a room which was clean. The bed mattress had a tear exposing the cushion, which made it unsantizable. The foot pedals and brakes on the bed had a build-up of dirt. There was an open trashcan that still had trash in it. Inside was a bloody dressing. The closed trashcan and biohazard bin in the room had foot pedals which had a build-up of dirt. An attachment to the pulse oximeter was soiled with a buildup of debris.

In the hallway was a cart which contained packets/bundles of sterile supplies and suture needles. Some of the bundles of sterile supplies were stored on the bottom shelf in close proximity to the floor. The inside of the bins were soiled with dust and spills. Three boxes of suture needles were on the cart and they expired January 2015.

According to the Guideline for Disinfection and Sterilization in Healthcare Facilities, 2008, page 75 revealed the following:

"Following the sterilization process, medical and surgical devices must be handled using aseptic technique in order to prevent contamination. Sterile supplies should be stored far enough from the floor (8 to 10 inches), the ceiling (5 inches unless near a sprinkler head [18 inches from sprinkler head]), and the outside walls (2 inches) to allow for adequate air circulation, ease of cleaning, and compliance with local fire codes (e.g., supplies must be at least 18 inches from sprinkler heads).


Main ED Waiting area

Inside the Women's bathroom was a dried substance that ran down the wall and onto the floor next to the sink. An unidentified patient/family member using the sink stated "someone vomited in here".

Two chairs, in the middle section of the waiting room, were soiled with a dried food spills. The floor underneath the chairs had food spills. The table next to the area had food spills on top of it.

The floor underneath and side of the vending machines had spills of debris and paper. One of the legs of the vending machine had caused a hole in the floor tile underneath resulting in the tile unable to be sanitized.

Triage room

The baseboards were soiled with a buildup of dirt and dust. The floor underneath one of the desk in the room was soiled with pieces of paper. One of the chairs had a seat cover that was ripped exposing the cushion inside.

Minor Care Area

A bed was stored in the hallway in front of the nursing station. There was a sign on it that read the side rail was broken.

Room #20 had a patient bed which still had soiled linen on it. The base of the bed was soiled with brown substance. On a table at the bedside was an open packet of antibiotic ointment and a used Q-tip (from a dressing change). Inside the same room were shelves of clean casting/splinting supplies and boxes of suture needles which were not covered.

Patient over flow room had holes in the wall where equipment had been taken off the wall. A trash can in the room was full of trash and had no liner in it.

Radiology equipment storage area outside of the ED had white accordion doors which were soiled with dirt and had turned brown. The floor underneath the doors were also soiled with dirt.

During an interview on 02/18/2015, Staff #2 confirmed the observations. She reported when the housekeeper cannot keep up the nursing staff wipe down the beds and picks up the trash. There was one housekeeper for the 6-2 p.m. shift. On the 2-10 p.m. and 10 p.m. - 6 a.m. shifts they have a housekeeper, but they have to be shared with other units. On the night shifts there were only two housekeepers in the entire hospital.

Review of environmental rounding sheet forms from September 2014 to February 2015 revealed the emergency room was checked once (October 2014).

During an interview on 02/18/2015 after 2:00 p.m., Staff #s' 4 and 6 reported environmental rounds were performed every Friday throughout the hospital. Staff #4 (Safety officer) confirmed October 2014 as being the only documentation of the ED environment being checked. Staff #6 confirmed not being aware of the condition of the ED and the October 2014 round being the only one she knew about.

Review of the policy named "General policies"and dated 08/2013 revealed one of the functions of the Emergency department revealed the following:

"To see that the facilities are not only medically ready for patients, but also clean and well maintained."

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

A. ensure nursing assessments were accurate and complete. The facility failed to ensure follow-up assessment s after medication administration were provided and thorough assessments prior to discharge in 7 of 26 Emergency Department (ED) patients (Patient #s'1, 2, 3, 5,7,23, and 24).

Review of an ED chart on Patient #1 revealed that she was an 8 year old, who presented to the ED on 09/01/2014 at 3:56 a.m. Patient #1 was triaged at 3:57 a.m., and given an Acuity level of 3 (non-urgent classification)and chief complaints were diarrhea and abdominal pain. Patient #1's vital signs were taken at this time and the pain level was listed as 10 out of 10 (0 indicating no pain and 10 indicating severe pain). Over an hour and a half later at 5:41 a.m., Bentyl (an agent used to reduce muscle spasms in the gastrointestinal tract) was administered. There was no documentation of an assessment of the patient vital signs or pain level before or after the medication. At 5:55 a.m. (14 minutes later) there was documentation Patient #1 was discharged from the ED and there was still no assessment of the pain level or vital signs.


Review of an ED chart on Patient #2 revealed that he was a 59 year old, who presented to the ED on 09/02/2014 at 8:28 a.m.. Patient #2 was triaged at 8:29 a.m. and given an Acuity level of 3 (non-urgent classification) and chief complaints were nausea and abdominal pain. Patient #2 had a pain level of 7 out of 10 and his vital signs were taken at 8:29 a.m.

At 9:00a.m., the antiemetic Zofran IVP (intravenous push) was administered and at 9:03 a.m., the pain agent Morphine IVP was administered.

At 9:42 a.m., there was documentation this was a reassessment after medication administration. The patient's overall status was the same and he still felt the same. The patient stated "Listen, I have to have something else for the pain. The last medication is not cutting it." There was no documentation of what the patient's pain level was at 9:42 a.m.

At 9:55 a.m., Patient #2 was given the pain agent Dilaudid IVP. There was no documentation of the pain level prior to medication administration. The reassessment after pain administration was at 10:42 a.m. (47 minutes later) when staff documented Patient #2 had a pain level of 7 out of 10. There was no documentation of what was done about the elevated pain level.

Review of an abdominal sonogram on the ED chart revealed that Patient #2 had gallstones and cholecystitis (inflammation of the gallbladder).

At 11:50 a.m., Patient #2 departed from the ED and was admitted into the hospital.

Review of an ED chart on Patient #3 revealed that she was a 67 year old who presented to the ED on 09/02/014 at 8:42 p.m. According to documentation Patient #3 was triaged at 8:41 p.m.(incorrect time) and given an acuity level of 3 (non-urgent classification). The chief complaints listed were a single syncopal episode, followed by chest pressure and shortness of breath. The patient's vital signs were documented as being 144/83, 77, 20, oxygen saturation 97 %, temperature 97.9 F and pain level of 10 out of 10. The physician assessed the patient at 9:28 p.m. (45 minutes after presenting). At 10:35 p.m. (over 1.5 hours after presenting) Patient #3 was given the pain medication Norco. At 11:16 p.m., the patient refused to be admitted and left against medical advice. There was no reassessment of the pain level or vital signs prior to medication administration or before discharge.


Review of an ED chart revealed Patient #7 was a 41 year old female, who presented on 02/13/2015 at 7:34 p.m.. The triage assessment was performed at 7:42 p.m. and Patient #7 had a complaint of chest pain. The pain level was 5 out of 10. No acuity level was documented on the assessment. At 7:51 p.m., nursing documented an EKG (electrocardiogram) was performed on the patient at 7:29 p.m. This timing was incorrect or the presentation time was incorrect. At 9:12 p.m., Patient #7 was ambulated to a hall with a visitor. According to documentation an apology was given for the wait and hall bed placement. At 9:19 p.m. (over 1.5 hours later) the physician performed his assessment. At 9:23 p.m., Patient #7 was given pain agents Motrin and Norco and there was no documentation of what the pain level.


Review of an ED chart revealed that Patient #5 was an 81 year old female, who presented on 02/13/2015 at 7:41 p.m. The triage assessment at 7:56 p.m. revealed that Patient #5 had a blood pressure of 192/79 and made complaints of being dizzy, chest discomfort with shortness of breath and having a headache. The acuity level was 3 (non-urgent classification). At 9:23 p.m. (almost 1.5 hours later) the blood pressure was 188/83. At 9:39 p.m. the physician assessed the patient and documented the chief complaint was the blood pressure was elevated. The following events occurred:
10:03 p.m., anti-anxiety agent Ativan administered;
10:19 p.m. the blood pressure was 181/76;
10:34 p.m., the blood pressure agent Lisinopril was administered (almost 3 hours after presenting to the ED with an elevated blood pressure);
11:08 p.m., the blood pressure was 192/87;
11:17 p.m. the blood pressure agent Clonidine was administered;
11:30 p.m., Patient #5 was discharged from the hospital. There was no documented follow-up of the blood pressure after administration of the Clonidine.


Review of an ED chart revealed that Patient #23 was a 36 year old female, who presented on 02/16/2015 at 2:08 p.m. According to documentation Patient #23 had an EKG performed by a hospital technician at 1:52 p.m. (before the recorded presentation time). According to documentation, the patient was called by nursing for room assignment at 2:36 p.m. and 3:16 p.m. There was documentation the patient left before a triage.

During an interview on 02/18/2015 after 2:00 p.m., Staff #2 confirmed the EKG was probably done on the patient first because of complaints made by the patient. The physician saw the EKG results and the patient was placed back in the waiting area. She confirmed there was documentation of an EKG being performed and being normal. There was no documentation of the physician's assessment prior to the patient being sent back to the waiting room.

Review of an ED chart revealed that Patient #24 was a 33 year old female, who presented to the ED on 02/18/2015 at 10:19 a.m.. Patient #24 was triaged at 10:44 a.m., and given an acuity level of 3(non-urgent classification). The chief complaints listed were spasms in the chest and back, feel like every time I eat it is getting stuck, vomiting and might be gallbladder. Patient #24 vital signs were listed as 159/109, 97, 18, oxygen saturation of 100 percent on room air, temperature 98.1 degrees Fahrenheit, and pain level of 10 out of 10. Patient #24 was given the antiemetic Zofran IVP and pain agent Morphine IVP at 11:14 a.m. and the gastric acid reduction agent Pepcid at 11:38 a.m. The next documented vital signs were at 11:48 a.m., but there was no follow-up on the pain level or the levated blood pressure.

During an interview on 02/18/2015 after 2:00 p.m., Staff #2 confirmed the problems with assessment, lack of follow-up after medication administration and problems with discharge assessment.

Review of a policy named "Patient Assessment and Reassessment in the ED" dated 08/2013 revealed the following:
"Initial Triage:
An initial Triage of all patients presenting to the Emergency Department will be performed immediately. The physician will be notified if the patient's condition is critical (See Triage policy).

Reassessments:
Reassessment of the ED patient's needs and condition is a continual nursing process and the frequency is determined by the patient's acuity. The ED RN or LVN must be able to detect changes in the patient's condition promptly and provide appropriate, rapid intervention. Reassessments will be done before discharge, transfer, or admission by RN/Midlevel."

Review of a policy named "Triage in the Emergency Department" dated 08/2013 revealed the following:

"All patients will be seen and evaluated by an RN in triage to determine the severity of illness or injury, rather than first come, first serve or time of arrival. Registration Clerks should notify the RN if anyone presents seeking treatment via the ambulatory door. They should also call if they feel anyone is in obvious distress such as: difficulty breathing, bleeding, chest pain, seizures, falling, felling faint, or in labor. If anyone waiting in the waiting area to be called to the treatment area exhibits any of the above, the clerk should also notify an RN. The above list includes certain criteria but anytime a clerk feels a patient or family member needs assistance hey should notify the RN."

"Patient Acuity System -Classification

CATEGORY 1-EMERGENT
Any patient whose condition is considered emergency by the triage nurse will be taken to the main treatment area where a nurse will be assigned to check-in the patient after a report. The triage nurse will initiate any urgently needed treatment."
CPR, Respiratory Distress and Cardiac chest pain were listed as some of the conditions classified as emergent.

"CATEGORY II- URGENT
Urgent patients will be triaged in the triage station. After triage, the shift manager will be notified of the patient. The patient will be brought to the treatment area within 30 minutes.
Patients who present with active vomiting and /or diarrhea, severe discomfort, or that need to lie down are considered urgent and are brought to the treatment area as soon as possible."
Severe hypertension with symptoms, Stroke/TIA, and Syncope were listed as some of the conditions classified Urgent.

"CATEGORY III- NON-URGENT
The non-urgent patient requires evaluation and treatment but time is not a critical factor. These patients describe non-debilitating discomfort and are able to continue to function."
Chronic headache, mild headache, non-acute GI symptoms, "Flu" symptoms, Non-acute abdominal pain and Chronic conditions were listed as some of the conditions classified as non-urgent.


B. ensure the environment in the emergency room was kept safe and sanitary.

During an observation of the ED on 02/18/2015 after 10:05 a.m. the following was found:

The hallways were cluttered with linen carts, supply carts, beds with and without patients, wheelchairs, scales and family members sitting in chairs. There was no clear pathway and the egress on both sides of the hallways was blocked. One unidentified patient sitting on a bed in the hallway had on a mask. Unoccupied patient rooms were found soiled and in need of cleaning. The rooms could be used for the patients in the hallways.

Review of the policy named "General policies"and dated 08/2013 revealed one of the functions of the Emergency department revealed the following:

"To see that the facilities are not only medically ready for patients, but also clean and well maintained."