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Based on interview and record review, the facility failed to ensure that the Condition of Participation [the terms healthcare organizations must meet in order to participate in federally funded healthcare programs] of Emergency Services was met as evidenced by:

1. The facility failed to ensure an organized patient care process by not completing assessment for medication interview and transfer records in the Emergency Department (ED) for four (4) of thirty sampled patients (Patient 2, Patient 3, Patient 30 and Patient 35).

a. For Patient 2:

a. i. Repeat vital signs (a measurement of the body's essential physiological functions) should have been done at least one hour after administration of Acetaminophen suppository (Tylenol, medication for lowering elevated body temperature). (Refer to A 1101).

a. ii. The discharge teaching record does not indicate a name of facility healthcare staff member who performed discharge teaching. (Refer to A 1101).

b. For Patient 3, 30, and 35, the transfer records were not completed. Patient 3, 30, and 35 had no Emergency Department Transfer form and no documentation of Transfer Consent form completed for Patient 3 transfer to higher level of care. (Refer to A 1101).

2. The facility staffs (Laboratory Assistant [LA] and Medical Doctor 1 [MD 1] in the Emergency Department failed to notify the next level of command (e.g., supervisor, manager/directors, or Chief Nursing Officer [CNO]) to report that supplies (laboratory blood tubes for pediatric [children under 18 years old] needed to draw and collect blood were not available according to facility's policy and procedure for Administrative Chain of Command," for one (1) of thirty sampled patients (Patient 2). Patient 2 had a physician order for blood test (Complete Blood Count ([CBC] a blood test to look at a patient overall health and find a wide range of conditions, including anemia [a condition when you do not have enough red blood cells), infection, and leukemia [cancer of the white blood cells]) and Basic Metabolic Panel ([BMP] a blood test that helps check the body's fluid balance and levels of electrolytes [essential minerals like sodium, calcium, and potassium], and see how well the kidneys are working). Patient 2's mother was informed to follow up with another facility to have the blood work done. (Refer A 1111).

The cumulative effect of these deficient practices resulted in the facility's inability to provide quality health care by the staff in the ED.

Based on interview and record review of facility documents, the facility failed to ensure an organized patient care process by not completing assessment for medication interview and transfer records in the Emergency Department (ED) for four (4) of thirty sampled patients (Patient 2, Patient 3, Patient 30, and Patient 35).

1. For Patient 2:

a. Repeat vital signs (a measurement of the body's essential physiological functions) should have been done at least one hour after administration of Acetaminophen suppository (Tylenol, medication for lowering elevated body temperature) and,

b. The discharge teaching record does not indicate a name of facility healthcare staff member who performed discharge teaching.

The deficient practice had the potential for Patient 2 and other patients not receiving assessment after treatment and discharge teaching not received by patient and/or family member caring for the patient.

2. For Patient 3, 30, and 35, the transfer records were not completed. Patients 3, 30, and 35 had no Emergency Department Transfer form and no documentation of Transfer Consent form completed for Patient 3 transfer to higher level of care.

The deficient practice resulted to for Patient 3, 30, and 35 being transferred without information when and how they (Patient 3, 30, and 35) were transferred safely to ensure the higher level of care was provided.

Findings

1. a. A review of Patient 2's "Face Sheet,'' an admission record, undated, indicated Patient 2 was admitted to the emergency department (ED) for fever (an abnormally high body temperature defined as 100.4 degrees Fahrenheit (F, unit of measurement), on 5/3/2023 at 10:33 P.M. via emergency medical service (EMS, an emergency services that provide urgent pre-hospital treatment and transportation).

A review of Patient 2's ED Summary Report dated 5/04/2023, indicated that upon arrival, Patient 2 was triaged with chief complaint as of fever and eight to ten episodes of diarrhea (passage of 3 or more loose stools per day). Patient 2's vital signs, on 5/3/2023 at 10:45 P.M., indicated a blood pressure (BP) of 108/79 millimeters of mercury (mmHg, unit of measurement), pulse (heart rate) 188 beats per minute (BPM), respirations 28 breaths per minute (BPM) and temperature 102.5 Fahrenheit ([F], equivalent to 39.2 C). The ED medical doctor (MD 1) noted that Patient 2, a 3-month and 16-day-old female, presented with a history of fever and MD 1 placed orders for chest radiograph (chest x-ray - an imaging test that uses x-rays to look at organs in the chest), Acetaminophen suppository (Tylenol), basic metabolic panel ([BMP] - a blood test that measures the body's naturally occurring chemicals, how the body uses food and energy) and complete blood count ([CBC] - a test that provides a count of the different cells that make up your blood in order to detect a wide range of conditions, including infections and blood disorders).

During concurrent interview with the Emergency Department Director (EDD), and record review of Patient 2's ED Report dated 5/3/2023, on 11/2/2023, at 3:13 P.M., EDD stated that RNs know that for pediatric patients (children under 18 years old) over thirty (30) days old presenting with fevers, treatment including initiating intravenous lines and blood tests should be escalated as sepsis (a life-threatening medical emergency due to the body's overwhelming response to an infection that can lead to tissue damage, organ failure and death) is an immediate possibility. EDD stated that phlebotomy staff (someone who collects blood from patients and prepare the samples for testing) are tasked with drawing blood, but RNs must follow up on all physician orders.


During a concurrent interview with the ED Clinical Supervisor (EDCS), and record review of Patient 2's ED Summary Report dated 5/04/2023, on 11/1/2023, at 2:53 P.M, the EDSC, stated Patient 2 had vital signs measured at triage on 5/3/2023 at 10:45 P.M. and the next set of vital signs logged were on 5/4/2023 at 12:28 A.M., just before discharge. EDSC stated that repeat vital signs should have been done at least one hour after administration of Acetaminophen suppository (Tylenol).

A review of the facility's policy and procedure titled Discharge from the Emergency Department last reviewed 8/2022, indicates documentation of discharge shall include the time the patient was discharged, who performed the discharge, vital signs measurement, including assessment of pain, clinical condition at time of discharge, and patient teaching/instructions that were provided with confirmation of understanding. A copy of the discharge instructions was provided to the patient, and they are asked to sign indicating that they have received the instructions, and the instructions have been reviewed with them.

1. b. A review of Patient 2's "Patient Visit Information (PVI - Discharge Instructions)," does not indicate a name of facility healthcare staff member who performed discharge teaching.

A review of the Patient 2's "Patient Signature Page (PSP - document provided for signature acknowledging discharge instructions)" does not indicate Patient 2's parent or guardian signature, date, or time nor facility's "caregiver/RN/Doctor" signature. In addition, PSP did not indicate Patient 2's parent refused to sign Patient 2's PSP.

During concurrent interview with ED Medical Director (EDMD), and record review of Patient 2's medical records, on 11/2/2023, at 9:46 A.M, EDMD stated at discharge or transfer, facility healthcare staff are tasked with signing documents (Patient Signature Page). EDMD also added per facility's policy and procedure, healthcare staff must retain copies and scan the records into the electronic medical record (EMR).

2. During a concurrent interview with the Performance Improvement Director (PI), and record review of Patient 3's ED Report dated 9/20/2023, on 11/1/2023, at 12:10 P.M, the PI stated Patient 3 was examined for lower left abdominal pain, and had emergent laboratory and diagnostic studies completed. PI stated Patient 3 was diagnosed with acute abdomen (sudden severe abdominal pain requiring urgent surgical evaluation). Patient 3's ED Report addendum note, dated 9/20/23, indicated Patient 3 would be transferred to a higher level of care for further evaluation and treatment. The record indicated Patient 3's father was notified about the transfer. The record indicated no documentation of when Patient 3 was transferred, what mode of transfer, and no documentation of consent for the transfer. PI director stated there was no documentation of Emergency Department Transfer form completed and no documentation of Transfer Consent form completed for Patient 3 transfer to higher level of care.

3. During a concurrent interview with the PI, and record review of Patient 30's Physician Summary Report and ED Transfer Form, dated 10/12/23, on 11/1/2023 at 12:12 P.M., the PI stated the Physician summary indicated Patient 35 was stable and was transferred to higher level of care. PI director stated Patient 30 had no documentation of completed transfer form and had no signed Transfer Consent form for Patient 30's transfer to higher level of care.

4. A record review of Patient 35's ED Report, dated 9/22/23 indicated Patient 35 was diagnosed with gastroenteritis (an infection in the digestive system causing vomiting and diarrhea), had emergent labs (laboratory) and diagnostic tests including blood tests done and was transferred to higher level of care.

A record review of Patient 35's ED Report, dated 9/22/23, indicated Patient 35 was diagnosed with breakthrough seizures (having a seizure after not having one for an extended period most often because of not taking prescribed seizure medication).

A concurrent interview with the PI, and record review of Patient 35's Physician Summary Report and ED Transfer Form dated 9/22/23, on 11/1/2023 at 12:12 P.M., with PI, PI stated the Physician Summary Report indicated Patient 35 was stable and was transferred to higher level of care. PI director stated there was no documentation of completed transfer form and signed Transfer Consent form for Patient 35's transfer to higher level of care.

A review of a facility documents titled "Emergency Department Approved for Pediatric (EDAP)" standards revised 1/1/23 indicated under Section 9, Quality improvement (QI) program requirements under section B. "identification and trending of important aspects of pediatric care requiring improvement shall include" 1. 100% medical record review by physicians and PdLN ..." (Pediatric Care Nurse Coordinator) and included Transfer to Higher Level of Care.

A review of the facility's policy and procedure titled Transfer of the Pediatric Patient dated 2/20/23 indicated "The Policy is to ensure most expeditious and appropriate transfer of the pediatric patient to another facility of higher level of care" and" all transfer forms must be completed and signed by parent or guardian, RN, and ER physician".

A review of the facility's policy and procedure titled "Consent, informed" dated 2/20/23 indicated "consent must be obtained whenever the patient is going to be touched by a care provider only licensed professionals can obtain and witness the patient's signature."

Based on interview and record review, the facility staffs (Laboratory Assistant [LA] and Medical Doctor 1 [MD 1] in the Emergency Department (ED) failed to notify the next level of command (e.g., supervisor, manager/directors, or Chief Nursing Officer [CNO]) to report that supplies (laboratory blood tubes for pediatric [children under 18 years old] needed to draw and collect blood were not available according to facility's policy and procedure for Administrative Chain of Command," for one (1) of thirty sampled patients (Patient 2). Patient 2 had a physician order for blood test (Complete Blood Count [CBC], a blood test to look at a patient overall health and find a wide range of conditions, including anemia [a condition when you do not have enough red blood cells]), infection, and leukemia [cancer of the white blood cells]) and Basic Metabolic Panel ([BMP] a blood test that helps check the body's fluid balance, levels of electrolytes [minerals in the body such as salt and potassium], and see how well the kidneys are working). Patient 2's mother was informed to follow up with another facility to have the blood work done.

The deficient practiced resulted to Patient 2's ordered blood test by physician not done and not get early diagnosis if blood test was completed to treat Patient 2 safely.

Findings:

A review of Patient 2's Emergency Report Record, dated 5/3/2023, indicated, Patient 2 was seen in the ED, on 5/3/2023 at 08:34 p.m., by Medical Doctor 1 (MD 1). The record indicated Patient 2 was a 3-months and 16-day-old female, who presented to the emergency department for history of fever. The records indicated a laboratory test of CBC and BMP were ordered on 5/3/2023 at 11 p.m. The record indicated MD 1 was informed by LA that the facility does not have the pediatric vacutainer to (sterile glass or plastic test tube with colored rubber stopper creating a vacuum seal inside of the tube, facilitating the drawing of a predetermined volume of liquid) obtain Patient 2's blood. The record indicated Patient's 2 mother was notified of the facility not having pediatric vacutainer, and Patient 2's mother was notified to follow up with another facility to have the blood work done. The record indicated Patient 2 was discharged to home at 11:06 p.m.

During an interview with the Director of Clinical Laboratory (DCL), on 11/01/2023, at 2:52 p.m., the DCL stated that the information given by the Laboratory Assistant (LA) to MD 1 was wrong. The facility did have available supplies of pediatric vacutainer at time of incident (5/3/2023 at 11 p.m.). The DCL stated the facility can also use regular (adult) vacutainer to do blood draw on a patient, who is 3 months old. Patient 2 was 3 months old and 16 days, and Patient 2 meet criteria to use the regular vacutainers. Facility had all the necessary equipment and supplies to process Patient's 2 CBC and BMP, on the 5/3/2023 laboratory orders. The DCL stated LA failed to adhere to the facility's "Chain of Command" policy and should have escalated the concern to her Supervisor or Director. The DCL stated If LA followed the "Chain of Command" policy, her Supervisor or Director would have able to guide her and educate her and resolve her concern. The DCL stated adhering to the policy would have prevented Patient 2 from being discharge without her CBC and BMP being done.

During an interview, on 11/02/2023, at 2:12 p.m., the Chief Nursing Officer (CNO) stated not having available pediatrics vacutainer and not completing diagnostic procedure like the laboratory orders of CBC and BMP was a patient safety concern and meets criteria to complete a report in the Incident Reporting System (a reporting tool used to provide a mechanism for tracking and trending areas of concern or potential concerns to assure patient safety improvements are made.) The CNO stated it is the facility's expectation and it is responsibility of the staff to immediately notify their supervisor. The Laboratory Assistant (LA) who reported to MD 1 that there was no available vacutainer to complete the CBC and BMP orders for Patient 2 failed to escalate the issue and complete an incident report.

During an interview, with the Director of Clinical Laboratory (DCL), on 11/03/2023, at 1:16 p.m., DCL stated LA should have escalated the concern of unavailability of pediatric tubes (vacutainers) to her senior Clinical Laboratory Scientist (supervisor). The DCL stated not having a pediatric tube in the facility was a patient safety concern and should have been immediately escalated to leadership.

A review of the facility's policy and procedure (P&P), titled, "Administrative Chain of Command," date of 7/2023, indicated when initiating the Chain of Command, a team member who was aware of a potential or actual issue, was accountable for making attempts to prevent or resolve the issue (within their scope of responsibility). If unresolved, the team member shall contact their immediate supervisor to alert them to the potential or actual issue. If still unresolved, the team member shall notify the next level of command (e.g., manager/director) during regular business hours or the House Supervisor after business hours. If unable to resolve, the CNO will be notified for resolution of the issue.

A review of the facility's policy and procedure (P&P), titled, "Incident reporting System", with last reviewed date of 03/2022, indicated an incident report should be filed in the event of error or potential error, or danger or potential danger to patients, visitors, employees. Examples of reportable incidents include diagnostic or therapeutic procedures that are delayed or not performed due to personnel, equipment, or facility.