HospitalInspections.org

Based on observation, interview, and record review, the Governing Body failed to ensure;

1. Hospital staff effectively promoted and protected the rights of patients (A115); and,

2. Emergency services were provided in a safe and effective manner to meet the needs of the patients and the community (A1100).

The cumulative effect of these systemic problems resulted in failure of the Governing Body to effectively fulfill it's responsibility to the patients and the community.

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

1. Seven of seven Medicare patients were given information related to the discontinuation (discharge or transfer) of their patient care (Patients 402, 403, 405, 407, 408, 409, and 410), resulting in the potential for the patients being unaware of their appeal rights at the time of discharge (A117):

2. Restraints were used safely on one of one ED (emergency department) patients placed in restraints (Patient 207) when the staff left her in bilateral ankle restraints only, the restraints were left on in the absence of behaviors to warrant the use of restraints, and the ED nurse did not monitor the condition of the patient while she was in restraints resulting in the potential for emotional and physical harm and death (A144);

3. Four of four patients identified as a danger to themselves or others (Patients 204, 205, 206, and 207) received constant monitoring and supervision from facility staff in accordance with the facility policy, resulting in the potential for the patients to cause injury or death to themselves, other patients, staff, or visitors in the ED (A144);

4. One of one ED (emergency department) patients placed in restraints (Patient 207), had the restraints discontinued when she stopped exhibiting behaviors warranting use of the restraints, resulting in unnecessary use of restraints, and the potential for injury and death to the patient (A154);

5. The use of restraints for one of five physically restrained patients (Patient 400) was in accordance with a written modification to the patient's plan of care, resulting in the potential for inconsistencies with the provision of care, and a potential for serious consequences including harm or death (A166);

6. ED staff monitored the condition of one of one ED patients while she was in restraints (Patient 207), resulting in the potential for injury and death to the patient (A175);

7. Use of the most appropriate interventions to manage the condition of one of five patients in restraints (Patient 400) when the medical record did not describe the patient's symptoms that warranted the use of restraints, resulting in the potential for restraints being applied that were not necessary, and the potential for emotional and physical harm to Patient 400 (A187).

The cumulative effect of these systemic problems resulted in failure to ensure effective promotion and protection of patient's rights.

Based on observation, interview, and record review, the facility failed to ensure seven of seven Medicare patients were given information related to the discontinuation (discharge or transfer) of their patient care (Patients 402, 403, 405, 407, 408, 409, and 410). The facility failed to provide a signed copy of the standardized notice, "An Important Message from Medicare" (IM notice), in advance of the patient's discharge, but not more than two calendar days before the patient's discharge.

This resulted in the potential for the patients being unaware of their appeal rights at the time of discharge.

Findings:

On March 19, 2014, at 1:45 p.m., the Inpatient Director (ID) was interveiwed. The Director stated the IM notice should be given to the patient by the nursed assigned to the patient. The Director stated the IM notice should be given to Medicare patients that were discharged or transferred to a skilled nursing facility.

a. During an interview with LN (licensed nurse) 7 on March 19, 2014, at 2:15 p.m., LN 7 stated he was not involved in distributing the IM notice to patients. LN 7 was preparing to discharge Patient 402. LN 7 stated he would print up discharge instructions for the patient but he would not be providing her with the IM notice.

Patient 402's record was reviewed on March 19, 2014. The record indicated Patient 402 was admitted to the facility on March 14, 2014. There was a signed IM notice in Patient 402's record dated March 13, 2014. There was no evidence in the record reflecting Patient 402 received a copy of the notice, within two days of discharge (March 15, 2014 or later).

b. During a facility tour on March 19, 2014, at 2:20 p.m., Patient 403 was observed being transferred to a gurney in preparation for her transport to a local skilled nursing facility. Patient 403's eyes were open and she responded to verbal stimuli.

Patient 403's record was reviewed. Patient 403 was admitted to the facility on March 14, 2014. The patient's initial IM notice was signed by the patient on March 14, 2014. The patient's record was reviewed with the ID who was unable to find a copy of the second notice, or a notice given to the patient within two days of her discharge.

c. During a tour of the fourth floor, on March 19, 2014, at 2:40 p.m., a board indicating discharged patients was observed. As the board indicated Patient 405 was transferred to a local skilled nursing facility, the patient's record was reviewed. The record contained an inital IM notice, signed on March 14, 2014. The IM was signed by the patient's son.

During an interview with the Patient Access Supervisor on March 19, 2014, at 1:50 p.m., the supervisor stated her department was responsible for providing the initial IM notice to patients upon admission. She stated the notice provided prior to discharge was the responsibility of the case management department.

During an interview with the Director of case management on March 19, 2014, at 2:05 p.m., the director stated case managers were not responsible for providing the IM notice to patients prior to discharge. She stated the nurses were supposed to provide the notice to patients with their discharge instructions.

During an interview with LN 9 on March 19, 2014, at 2:20 p.m., the LN stated she had seen the IM notice before, but she had never given it to a patient. LN 9 stated she did not know what the IM notice was for.

During an interview with LN 8 on March 19, 2014, at 2:45 p.m., LN 8 stated the admitting department obtained the patient's signature on the initial IM notice. LN 8 stated she was not required to give the patient another copy prior to their discharge.

During an interview with CN (charge nurse) 2 on March 19, 2014, at 2:45 p.m., the CN stated the IM notices should be given at discharge. The CN stated the forms let the patients know their right to appeal the order for discharge.

On March 20, 2014, a list of Medicare Inpatient Discharges was reviewed, for Medicare inpatients that were discharged greater than four days following their admission. The following was noted:

d. Patient 407 was admitted to the facility on January 28, 2014. Patient 407's record did not contain a copy of the IM notice. Patient 407 was transferred to a skilled nursing facility on Febraury 7, 2014.

e. Patient 408 was admitted to the facility on Febraury 3, 2014. The record contained copies of the patient's discharge instructions but did not contain either an initial or a second copy of the IM notice.

f. Patient 409 was admitted to the facility on Janaury 26, 2014, and transferred to the subacute unit on February 18, 2014. There was no evidence in the record the patient received either an initial IM notice or one within two days of transfer.

g. Patient 410 was admitted on February 17, 2014, and discharged home on March 4, 2014. There was no evidence in the record the patient received either an initial IM notice or one within two days of transfer.

During an interview with the Director of Health Information Managment, on March 20, 2014, at 11:10 a.m., the Director stated the IM notices should be scanned into the patients' electronic record. The Director stated she checked each of these patient's scanned documents and was unable to find the IM notice.

A document titled "An Important Message from Medicare About Your Rights," was reviewed on March 20, 2014. The document indicated a hospital inpatient had a right to receive medically necessary hospital services, and know who will pay for them and where to get them. In addition, the patient has the right to appeal a discharge decision and have the discharge reviewed by a Quality Improvement Organiztion (QIO). According to the document. "If you want to appeal, you must contact the QIO no later than your planned discharge date and befoer you leave the hospital."

During an interview with the CNO (Chief Nursing Officer) on March 29, 2014, at 10:40 a.m., the CNO stated the facility did not have a policy regarding who was responsibile for providing the IM notices to Medicare patients.

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

1. Restraints were utililzed safely for one emergency department (ED) patient placed in restraints (Patient 207) when the staff left the patient alone after applying bilateral ankle restraints. The restraints were left in place when the absence of patient behaviors might have warranted the removal of the restraint. In addition, the ED nurse did not monitor the patient's condition while she was in restraints. This failed practice resulted in the potential for emotional and physical harm and death; and,

2. Four of four patients identified as a danger to themselves or others (Patients 204, 205, 206, and 207) received constant monitoring and supervision from facility staff in accordance with the facility policy. This failed practice resulted in the potential for the patients to cause injury or death to themselves, other patients, staff, or visitors in the ED.

Findings:

1. During a tour of the ED on March 17, 2014, at 9:20 p.m., a facility employee was observed sitting in the hallway by a patient room. The employee stated she was a sitter, assigned to monitor two patients who were placed on 5150 holds (involuntary psychiatric hold for persons who are a danger to self, others, or gravely disabled). The sitter stated one of the patients monitored was Patient 207, who was down the hall. The sitter stated Patient 207 was aggressive when she first arrived, but she was now sleeping, "With two restraints on," so Patient 207, "Should be OK."

On March 17, 2014, at 9:21 p.m., Patient 207 was observed laying in bed, sleeping soundly, with bilateral (both sides) soft ankle restraints in place, which were tied to the bed frame. There was no evidence of any other restraints.

On March 17, 2014, at 9:15 p.m., Security Officer 1 was asked to assist in observing Patient 207's restraints. The officer pulled back the blanket covering Patient 207 and exposed bilateral soft ankle restraints that were tied to the bed frame. No other restraints were observed. The officer visualized the restraints and stated only the patient's ankles were tied. The officer stated the patient did not have restraints applied anywhere else. The officer covered the patient and left the room. Patient 207 slept soundly, without moving or waking up, during this interaction.

On March 17, 2014, at 9:30 p.m., the ED CN (charge nurse) was asked to assist in observing Patient 207's restraints. The CN pulled back the blanket covering Patient 207 and exposed bilateral soft ankle restraints that were tied to the bed frame. No other restraints were observed. The CN stated only the patient's ankles were tied and Patient 207 did not have restraints anywhere else. The CN covered the patient and left the room. Patient 207 slept soundly, without moving or waking up, during this interaction.

During an interview with LN 1 (the nurse caring for Patient 207), the LN stated the patient had bilateral wrist and bilateral ankle restraints on when she got to the ED, and was dirty, so the LN, "Cleaned her up." The LN stated she did not know if there was an order for the restraints. The LN stated, after cleaning the patient, she medicated her (with a medication for agitation) and removed the wrist restraints. LN 1 stated, when she administered the medication (by injection into the leg muscle), the patient started kicking, so her ankles "stayed tied." LN 1 stated she did not know if the restraints were still on her patient. The LN stated she did not know if "they" removed them (she defined "they" as security). The LN stated Patient 207 did not need the restraints anymore because she was calm. She stated, "If they are still on, I will take them off."

The record for Patient 207 was reviewed on March 19, 2014. Patient 207, a 67 year old female, was taken to the ED by ambulance on March 17, 2014, after an overdose of medication. The record indicated the patient was agitated on arrival to the ED, and became calm after medication was administered. The record included a physician's order for bilateral soft wrist restraints and bilateral soft ankle restraints. There was no evidence in the record of the ED nurse monitoring the patient's restraints.

Although the patient was not exhibiting behaviors that warranted the use of restraints and the nurse stated the patient did not need to be restrained, Patient 207 remained in bilateral ankle restraints.

The facility policy titled, "Restraint and Seclusion," was reviewed on March 19, 2014. The policy indicated assessments would be completed by the LN as often as indicated by the patient's condition, behavior, and environmental consideration and at least every two hours.

2. During a tour of the ED on March 17, 2014, at 9:20 p.m., a staff member (Sitter 1) was observed in the hallway, outside of a four bed area where Patient 204 was resting on a gurney.

During an interview with Sitter 1 on March 17, 2014, at 9:20 p.m., she stated she was a sitter for two different patients (Patient 204 and 207) at the same time, who were both on 5150 holds (involuntary psychiatric hold for persons who are a danger to self, others, or gravely disabled). Sitter 1 stated Patient 207 was located across and down the hall from Patient 204. Sitter 1 stated she was not able to fully visualize Patient 207 while she was seated near Patient 204's room, but she would frequently walk over to see how Patient 207 was doing. Sitter 1 further stated Patient 207 was very agitated and aggressive when the patient first arrived at the ED, but now Patient 207 was sleeping, "with two restraints on," so Patient 207, "should be ok."

Patient 207 was observed on March 17, 2014, at 9:21 p.m., located across the hall approximately 15 feet down (past the nurse's station) from Patient 204. Patient 207 was resting in bed, with bilateral soft ankle restraints in place, tied to the bed frame.

During a second interview with Sitter 1 on March 17, 2014 at 9:45 p.m., she stated she received a third patient (Patient 205) to observe. The sitter stated Patient 205 was also on a 5150 hold. She stated Patient 205 was located in the room across from Patient 207. Sitter 1 stated she was waiting for staff to move all three patients into the same area so she could visualize them at the same time, instead going back and forth from room to room. Sitter 1 stated the three patients could not be moved until some of the other patients on the unit were discharged.

On March 17, 2014, at 9:45 p.m., Patient 205 was observed on a gurney in a room across the hall from Patient 207. Patient 205 was resting on the gurney with the privacy curtain closed around the gurney.

During a third interview with Sitter 1 on March 17, 2014, at 11:40 p.m., the sitter stated she had just received a fourth patient (Patient 206) who was also a 5150 hold. Sitter 1 stated Patient 206 was located in the same room on a gurney next to Patient 205. Sitter 1 stated she would frequently get up and check on each patient, but she was not able to fully visualize each patient due to the patients being in different proximities from each other. When Sitter 1 was asked if she ever had to be a sitter for more than four patients at one time she stated, "Occasionally, and when that happens the security officer helps me watch the other patients until the number comes back down to only four patients."

On March 17, 2014, at 11:40 p.m., Patient 206 was observed in the same room on a gurney next to Patient 205. Patient 206 was resting on the gurney and had the privacy curtain closed around the gurney.

a. The record for Patient 204 was reviewed. Patient 204 presented to the ED after an attempted suicide. The record indicated patient 204 was, "at imminent risk to self,".

b. The record for Patient 207 was reviewed. Patient 207 presented to the ED after an attempted suicide.

c. The record for Patient 205 was reviewed. Patient 205 presented to the ED after an attempted suicide.

d. The record for Patient 206 was reviewed. Patient 206 presented to the ED after a drug overdose, and was being treated for severe depression.

The facility policy titled, "Sitters," with a revised date of February 2014, indicated the sitter was to, "Provide direct observation of a patient that may bring harm to himself/herself or others."

The facility job description titled, "Patient Sitter," with a revised date of April 2012, indicated the patient sitter, "Remains in constant attendance with the patient."

The facility policy titled, "Management of Psychiatric Patients in the Emergency Department," was reviewed on March 19, 2014. The policy indicated a patient on an involuntary hold would be under constant surveillance by security officers and/or sitters.

With four patients located in various areas in the ED and assigned to one sitter, the sitter was unable to maintain constant observation of the patients and ensure they were safe and not posing a threat to themselves or other patients, staff, or visitors.

Based on observation and interview, the facility failed to ensure one ED (emergency department) patient placed in restraints (Patient 207), had the restraints discontinued when the patient stopped exhibiting behaviors which warranted use of the restraints. This failed practice resulted in unnecessary use of restraints, and the potential for injury and death to the patient.

Findings:

During a tour of the ED on March 17, 2014, at 9:20 p.m., a facility employee was observed sitting in the hallway by a patient room. The employee stated she was a sitter, assigned to monitor two patients who were placed on 5150 holds (involuntary psychiatric hold for persons who are a danger to self, others, or gravely disabled). The sitter stated one of the patients she was monitoring was Patient 207, who was down the hall. The sitter stated Patient 207 was aggressive when she first arrived, but she was now sleeping "with two restraints on" so Patient 207 "should be OK."

On March 17, 2014, at 9:21 p.m., Patient 207 was onserved laying in bed, sleeping soundly, with bilateral (both sides) soft ankle restraints in place, tied to the bed frame. There was no evidence of any other restraints.

On March 17, 2014, at 9:15 p.m., Security Officer 1 was asked to assist in observing Patient 207's restraints. The officer pulled back the blanket covering Patient 207 and exposed bilateral soft ankle restraints that were tied to the bed frame. No other restraints were observed. The officer visualized the restraints and stated only her ankles were tied. The officer stated she did not have restraints anywhere else. The officer covered the patient and left the room. Patient 207 slept soundly, without moving or waking up, during this interaction.

On March 17, 2014, at 9:30 p.m., the ED CN (charge nurse) was asked to assist in observing patient 207's restraints. The CN pulled back the blanket that was covering Patient 207 and exposed bilateral soft ankle restraints that were tied to the bed frame. No other restraints were observed. The CN visualized the restraints and stated only her ankles were tied. The CN stated she did not have restraints anywhere else. The CN covered the patient and left the room. Patient 207 slept soundly, without moving or waking up, during this interaction.

During an interview with LN 1 (the nurse caring for Patient 207), the LN stated the patient had bilateral wrist and bilateral ankle restraints on when she got to the ED. The LN stated she did not know if there was an order for the restraints. The LN stated, after cleaning the patient, she medicated her (with a medication for agitation) and removed the wrist restraints. LN 1 stated when she administered the medication (by injection into the leg muscle), the patient started kicking, so her ankles "stayed tied." LN 1 stated she did not know if the restraints were still on her patient. The LN stated she did not know if "they" removed them (she defined, "they," as security). The LN stated Patient 207 did not need the restraints anymore because she was calm now. She stated, "If they are still on, I will take them off."

Although the patient was not exhibiting behaviors that warranted the use of restraints and the nurse stated the patient did not need to be restrained, Patient 207 remained in bilateral ankle restraints.

Based on observation, interview, and record review, the facility failed to modify one of five physically restrained patient's (Patient 400) care plan to address the use of bilateral wrist restraints in order to ensure the use of restraints was in accordance with written modifications to the patient's plan of care. This failed practice resulted in the potential for inconsistencies with the provision of care, and a potential for serious consequences including harm or death.

Findings:

During a facility tour on March 19, 2014, at 9:45 a.m., Patient 400 was observed in bed in the CCU (Coronary Care Unit). Patient 400 was laying quietly with her eyes closed. Patient 400 was receiving supplemental oxygen via nasal cannula and intravenous (IV-line placed into vein) fluids. A nurse's workstation was observed outside the patient's room.

On March 19, 2014, at 9:45 a.m., LN (licensed nurse) 12 was interviewed about Patient 400's care. LN 12 stated the patient was in bilateral wrist restraints earlier in the day, but she (the nurse) removed them when she started her shift. LN 12 stated Patient 400 had not made any attempts to remove medical equipment such as her oxygen or IV lines that morning, so a trial release was being attempted.

Patient 400's record was reviewed. Patient 400 was admitted to the CCU on March 17, 2014, with diagnoses including an altered level of consciousness. Patient 400's History and Physical dated March 18, 2014, indicated, "When she came in, she was somewhat oriented despite having a history of being intermittently very confused." The physician documented: "Essentially non-responsive...who is moaning only."

The patient's E (Electronic) record was reviewed with the Inpatient Director (ID). The assessment flow sheet indicated soft wrist restraints were applied on March 19, 2014, at 2 a.m., due to, "Attempting to get up, feet moving as if trying to walk..." There was no evidence of violent behavior or attempts to remove medical equipment such as her oxygen or IV lines.

During a concurrent interview with the ID, on March 19, 2014, at 10 a.m. the ID stated there was no documentation in the record to validate the placement of wrist restraints. The ID stated the nurse should have documented, "In a group note, and indicate why the restraint was placed. I do not see that."

On March 19, 2014, at 1:15 p.m., a second visit was made to the CCU to continue reviewing Patient 400's record. The physician's order for the wrist restraint was reviewed. The order was on a "Safety/Behavioral Restraint Assessment and Physician's Order," form, and indicated the restraint was for behavior that was "Violent or Self -destructive." The order was signed by the physician, dated March 19, 2014, but was not timed.

On March 19, 2014, at 1:15 p.m., Patient 400 was observed lying in bed with a visitor at the bedside. Patient 400 had a wrist restraint wrapped around her left arm, that was not attached to the bed. Patient 400's visitor stated, "She recognized me, but has been asleep for most of the time I was here."

During an interview with the ID, on March 19, 2014, at 3 p.m., the ID was unable to find a care plan related to the use of restraints on Patient 400. The ID stated it would be in the section for "Risk for injury, related to restraints."

On March 20, 2014, at 11:15 a.m., the Intensive Care Unit Director (ICUD) was interviewed. The ICUD stated, if a patient was at high risk for falls, the nurses were instructed to move the work station close to the room to observe the patient. The ICUD stated,"Risk for falls," was not an appropriate indication for bilateral wrist restraints.

The facility policy and procedure titled, "Restraint and Seclusion," with a last revised/Reviewed date of September 2012, was reviewed. The policy indicated, "The patient has the right to safe implementation of restraint or seclusion by trained staff. All patients have the right to be free from restraint or seclusion, of any form imposed as means of coercion, discipline, convenience or retaliation by staff." A restraint was defined as any manual method that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely.

The policy indicated a restraint applied to manage violent or self-destructive behavior that jeopardized the immediate safety of the patient, staff members or others could remain in effect, "No longer than 4 hours for adults 18 years of age or older."

The policy indicated, "The restrained or secluded patient's written plan of care shall be modified to address appropriate interventions implemented to assure the patient's safety and encourage the least restrictive form of restraint as well as the prompt discontinuation of its use."

The policy references included the, "Medicare conditions of Participation: 42 CFR 482.13 (e) and (f)."

There was no evidence in the record of an acceptable reason for applying the restraints, or a modification to the plan of care that addressed the need for restraints or interventions to ensure the safety of the Patient 400.

Based on observation, interview, and record review, the facility failed to ensure ED (emergency department) staff monitored the condition of one ED patient while the patient was in restraints (Patient 207). This failed practice resulted in the increased potential for injury and death to the patient.

Findings:

During a tour of the ED on March 17, 2014, at 9:20 p.m., a facility employee was observed sitting in the hallway by a patient room. The employee stated she was a sitter, assigned to monitor two patients who were on 5150 holds (involuntary psychiatric hold for persons who are a danger to self, others, or gravely disabled). The sitter stated one of the patients she was monitoring was Patient 207, who was down the hall. The sitter stated Patient 207 was aggressive when she first arrived, but she was now sleeping, "With two restraints on," so Patient 207, "Should be OK."

On March 17, 2014, at 9:21 p.m., Patient 207 was onserved laying in bed, sleeping soundly, with bilateral (both sides) soft ankle restraints in place tied to the bed frame. There was no evidence of any other restraints.

On March 17, 2014, at 9:15 p.m., Security Officer 1 was asked to assistthe surveyor in observing Patient 207's restraints. The officer pulled back the blanket covering Patient 207 and exposed bilateral soft ankle restraints that were tied to the bed frame. No other restraints were observed. The officer visualized the restraints and stated only the patient's ankles were tied. The officer stated the patient did not have any other restraints. The officer covered the patient and left the room. Patient 207 slept soundly, without moving or waking up, during this interaction.

On March 17, 2014, at 9:30 p.m., the ED CN (charge nurse) was asked to assistthe surveyor in observing Patient 207's restraints. The CN pulled back the blanket covering Patient 207 and exposed bilateral soft ankle restraints that were tied to the bed frame. No other restraints were observed. The CN visualized the restraints and stated only the Patient 207's ankles were tied. The CN stated the patient did not have restraints anywhere else. The CN covered the patient and left the room. Patient 207 slept soundly, without moving or waking up, during this interaction.

During an interview with LN 1 (the nurse caring for Patient 207), the LN stated the patient had bilateral wrist and bilateral ankle restraints on when she got to the ED. The LN stated she did not know if there was an order for the restraints. The LN stated, after cleaning the patient, she medicated her (with a medication for agitation) and removed the wrist restraints. LN 1 stated, when she administered the medication (by injection into the leg muscle), the patient started kicking, so her ankles, "Stayed tied." LN 1 stated she did not know if the restraints were still on her patient. The LN stated she did not know if "they" removed them (she defined, "they," as security). The LN stated Patient 207 did not need the restraints anymore because she was calm. She stated, "If they are still on, I will take them off."

The record for Patient 207 was reviewed on March 19, 2014. Patient 207, a 67 year old female, was taken to the ED by ambulance on March 17, 2014, after an overdose of medication. The record indicated the patient was agitated on arrival to the ED, and became calm after medication was administered. The record included a physician's order for bilateral soft wrist restraints and bilateral soft ankle restraints. There was no evidence in the record of restraint monitoring by the ED nurse.

The facility policy titled, "Restraint and Seclusion," was reviewed on March 19, 2014. The policy indicated assessments should be completed by the LN as often as indicated by the patient's condition, behavior, and environmental consideration, and at least every two hours.

Based on observation, interview, and record review, the facility failed to ensure restraints were utilized as an appropriate response to documented patient behaviors for one patient (Patient 400), who had a physicians order for restraint use during episodes of violent or self injurious behaviors and had soft wrist restraints applied in response to the patient removing medical equipment. This failed practice increased the potential for restraints being applied that were not necessary, and the potential for emotional and physical harm to Patient 400.

Findings:

During a facility tour on March 19, 2014, at 9:45 a.m., Patient 400 was observed laying quietly in bed with her eyes closed on the CCU (Coronary Care Unit). Patient 400 was receiving supplemental oxygen via nasal cannula and intravenous (IV-line placed into vein) fluids. A nurse's workstation was observed outside the patient's room.

On March 19, 2014, at 9:45 a.m., LN (licensed nurse) 12 was interviewed about Patient 400's care. LN 12 stated the patient had been in bilateral wrist restraints, earlier in the day, but she (the nurse) removed them when she started her shift. LN 12 stated Patient 400 had not made any attempts to remove medical equipment such as her oxygen or IV lines that morning, so a trial release of the restraints was being attempted.

Patient 400's record was reviewed. Patient 400 was admitted to the CCU on March 17, 2014, with diagnoses that included an altered level of consciousness. Patient 400's History and Physical dated March 18, 2014, indicated, "When she came in, she was somewhat oriented despite having a history of being intermittently very confused." The physician documented: "essentially non-responsive...who is moaning only."

The patient's E (Electronic) record was reviewed with the Inpatient Director (ID). The assessment flow sheet indicated soft wrist restraints were applied on March 19, 2014, at 2 a.m., due to, "Attempting to get up, feet moving as if trying to walk..." There was no evidence of violent behavior or attempts to remove medical equipment such as her oxygen or IV lines.

During a concurrent interview with the ID, on March 19, 2014, at 10 a.m. the ID stated there was no documentation in the record to validate the placement of wrist restraints. The ID stated the nurse should have documented, "In a group note, and indicate why the restraint was placed. I do not see that."

On March 19, 2014, at 1:15 p.m., a second visit was made to the CCU to continue reviewing Patient 400's record. The physician's order for the wrist restraint was reviewed. The order was on a "Safety/Behavioral Restraint Assessment and Physician's Order" form and indicated the restraint was for behavior categorized as "Violent or Self -destructive." The order was signed by the physician and dated March 19, 2014. The order did not have a noted time it was received.

On March 19, 2014, at 1:15 p.m., Patient 400 was observed lying in bed with a visitor at the bedside. Patient 400 had a wrist restraint wrapped around her left arm and not attached to the bed. Patient 400's visitor stated, "She recognized me, but has been asleep for most of the time I was here."

During an interview with the ID, on March 19, 2014, at 3 p.m., the ID was unable to find a care plan related to the use of restraints for Patient 400. The ID stated it should be in the section labeled, "Risk for injury, related to restraints."

On March 20, 2014, at 11:15 a.m., the Intensive Care Unit Director (ICUD) was interviewed. The ICUD stated if a patient was at high risk for falls, the nurses were instructed to move the work station close to the room to observe the patient. The ICUD stated, "Risk for falls," was not an appropriate indication for bilateral wrist restraints.

The facility policy and procedure titled "Restraint and Seclusion," with a last revised/reviewed date of September 2012, was reviewed. The policy indicated "The patient has the right to safe implementation of restraint or seclusion by trained staff. All patients have the right to be free from restraint or seclusion, of any form imposed as means of coercion, discipline, convenience or retaliation by staff." A restraint was defined as any manual method that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

The policy indicated a restraint applied to manage violent or self-destructive behavior that jeopardized the immediate safety of the patient, staff members or others could remain in effect, "No longer than 4 hours for adults 18 years of age or older."

The policy indicated "The restrained or secluded patient's written plan of care shall be modified to address appropriate interventions implemented to assure the patient's safety and encourage the least restrictive form of restraint as well as the prompt discontinuation of its use."

The policy references included the "Medicare conditions of Participation: 42 CFR 482.13 (e) and (f)."

There was no indication in the record which specified behaviors which would prompt staff to consider the use of restraints for Patient 400.

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

1. Four of five ED (emergency department) patients who arrived by ambulance were triaged appropriately (assigned a level of severity [ESI] consistent with their illness or injury) when they were assigned ESI levels of three instead of two (Patients 101, 301, 302, and 400). This failed practice resulted in delays in providing a timely and appropriate MSE (medical screening examination) for the purposes of determining whether an emergency medical condition existed;

2. Four of four ED patients arriving by ambulance were received by the ED staff in a manner consistent with standards of practice for accepting report on ED patients, when the ED staff did not assume care of them until they were removed from the ambulance gurney and placed in an ED bed (Patients 101, 301, 302, and 400). This failed practice resulted in delays in treating patients with serious injury or illness, and delay in allowing EMS (Emergency Medical Service) personnel to return to provide any needed emergency services to the community;

3. Vital signs, pain levels, and response to interventions were reassessed for five of 20 patients reviewed (Patients 302, 304, 400, 110, and 121). This failed practice resulted in the potential for unrecognized deterioration in patient's conditions, and the inability to determine if interventions were effective and patients were discharged safely;

4. 14 of 16 patients determined to be appropriate for treatment in the RME (rapid medical evaluation) area were seen by a provider within 30 minutes of arrival in accordance with Governing Body recommendations (Patients 106, 108, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, and 121). This failed practice resulted in delays in assessment and treatment of patients in the RME area;

5. Medication administration was documented for one of one patient who was administered an anti anxiety medication (Patient 303), resulting in the potential for overmedication of the patient;

6. Appropriate integration of emergency services and radiology services, resulting in the potential for patients to go without appropriate treatment for emergency conditions, and patient harm or death (A1103); and,

7. The staffing plan for nursing and medical staff was adequate to meet the needs of the ED (Emergency Department) patients, resulting in the potential for harm and death in patients presenting to the ED for care (A1112).

The cumulative effect of these systemic problems resulted in failure to ensure emergency services were provided in a safe and effective manner to meet the needs of the patients and the community.

Findings:

1. The ESI (Emergency Severity Index) is a five level tool used by nurses to triage patients in the ED (Emergency Department). Patient acuity (severity of illness or injury) is rated from level one (most urgent and requiring immediate evaluation and treatment) to level five (least urgent and requiring the least amount of resources to evaluate and treat the patient).

ESI guidelines for the facility indicated ESI levels corresponded with patient acuity as follows:

ESI Level One (Resuscitation) - Patient requires immediate life saving intervention. When ESI Level One condition is identified, the triage process stops, the patient is taken directly to a room, and immediate physician intervention is requested;

ESI Level Two (Emergent) - The patient presents with a condition posing a potential threat to life, limb, or function and requires rapid medical intervention. These include high risk situations. Patients who might fall into level two are those with heart rate, respiratory rate or oxygen saturation rate in the danger zone. Danger zone vitals signs for adult are a heart rate greater than 100, respiratory rate greater than 20 and an oxygen saturation rate less than 92 %. When ESI Level Two condition is identified, the triage process stops, the patient is taken directly to a room, and immediate physician intervention is requested;

ESI Level Three (Urgent) - The patient presents with a condition that could progress to a serious problem. The presenting condition is anticipated to require utilization of two or more resources (lab, radiology, EKG, respiratory, etc.); and,

ESI Level Four (Semi Urgent) - The patient presents with a condition that has a low potential for deterioration or complications. One resource is expected to treat this patient.

a. During an interview with the family member of Patient 101 on January 9, 2014, at 4:30 p.m., the family member stated the patient was taken to the facility by ambulance the night of November 28, 2013, with a complaint of severe head pain. The family member stated Patient 101 had a brain aneurysm in the past, and this felt just like the other aneurysm. The family member stated when she arrived at the facility, she entered the ED to visit Patient 101, and saw her in the hallway on an ambulance gurney, where she stayed for, "about one hour," before she was moved to an ED bed. The family member stated the ED staff did not seem to be in a hurry to assist Patient 101, and it was not until the patient was placed in an ED bed and started breathing (agonal [gasping] type description) respirations, that the staff responded with seriousness.

The record for Patient 101 was reviewed. The record indicated Patient 101, a 79 year old female, presented to the ED via EMS (Emergency Medical Services [ambulance]) on November 28, 2013, with a chief complaint of sudden onset of a headache and a history of a brain aneurysm. According to the EMS record, upon their arrival to her home, the patient was holding her head in her hands, had sudden onset of a headache with pain 10/10 on a pain scale of 0-10 (10 being the worst pain), had nausea and vomiting, and had HTN (high blood pressure). The record indicated Patient 101's BP (blood pressure) was 204/100 (normal 120/80) upon EMS arrival to her house, they transported her to the hospital, and arrived there at 11:39 p.m.

The ED record indicated Patient 101 arrived at 11:45 p.m., and was triaged by LN (licensed nurse) 2 at six minutes after midnight (21 minutes after arrival to the ED). The record indicated Patient 101 had a history of a brain aneurysm, was complaining of a headache (10/10 on the pain scale), had a BP of 204/100 (the same BP obtained by the EMS personnel), and was restless. Patient 101 was assigned an ESI of three (urgent).

During an interview with the ED director on January 23, 2014, the director stated the condition Patient 101 presented to the ED with should have been assigned an ESI level two (with the physician being notified immediately), not a level three.

During an interview with the CNO on March 18, 2014, at 11:50 a.m., the CNO stated during the facility investigation into the care of Patient 101, LN 2 indicated she used the vital signs (including BP) taken by EMS prior to arrival at the ED for her triage vital signs. LN 2 indicated she did not retake the vital signs on arrival. LN 2 further indicated Patient 101 stayed on an ambulance gurney until she was moved to an ED bed (about one hour later), and she was not seen by a physician during that time.

Patient 101 was not triaged in compliance with the facility policy (should have been an ESI level two).

b. On March 18, 2014, the record for Patient 301 was reviewed. The EMS "Patient Care Report," indicated EMS was dispatched to Patient 301's home on March 17, 2014, at 7:30 p.m., for complaints of "Difficulty speaking." The report indicated the onset of symptoms was 45 minutes earlier. The medical record, "Triage Report," indicated Patient 301 arrived to the ED, via ambulance, on March 17, 2014 at 8:22 p.m., with complaints of slurred speech (one hour and 20 minutes after the onset of symptoms). The triage time was at 8:47 p.m., by LN 10. Patient 301 was assigned a ESI level 3 (Urgent).

Patient 301 was not triaged in compliance with the facility policy (should have been an ESI level two).

c. On March 18, 2014, the record for Patient 302 was reviewed. The "Triage Report," indicated Patient 302 arrived to the ED, via ambulance, on March 17, 2014 at 9:31 p.m. The triage time was 10:47 p.m., (when the patient was placed in an ED bed, and one hour and 16 minutes after arrival to ED), with complaints, per EMS, "Had 8 beers, became dizzy, fell slowly to the floor, no LOC [loss of consciousness] in C-spine." Patient 302 complained of pain to the right hip of 6/10 and was assigned an ESI level 3 (Urgent).

Patient 302 was not triaged in compliance with the facility policy (should have been an ESI level two).

d. The record for Patient 400 was reviewed on March 19 and 20, 2014. Patient 400, a 73 year old female, was brought to the ED, on March 17, 2014, by paramedics. According to the EMS report, Patient 400 was found laying on the floor with severe tremors (shaking) throughout her body. Patient 400's skin assessment indicated "Hot Temperature." Patient 400 arrived at the facility at 10:05 a.m., and was triaged at 10:27 a.m.

The triage record indicated the patient's initial temperature was 105.6 degrees Fahrenheit (normal 98.6), her heart rate was 146 beats per minute (normal adult rates 60-100), and her respiratory rate was 28 per minute (normal 12-20). The triage note indicated Patient 400, "was found on the floor, altered, shaking, on arrival..." She was assigned an ESI level 3 (urgent).

Patient 400 was not triaged in compliance with the facility policy (should have been an ESI level two).

2. a. During an interview with the family member of Patient 101 on January 9, 2014, at 4:30 p.m., the family member stated the patient was taken to the facility by ambulance the night of November 28, 2013, with a complaint of severe head pain. The family member stated Patient 101 had a brain aneurysm in the past, and this felt just like the other aneurysm. The family member stated when she arrived at the facility, she entered the ED to visit Patient 101, and saw her in the hallway on an ambulance gurney, where she stayed for, "about one hour," before she was moved to an ED bed. The family member stated the ED staff did not seem to be in a hurry to assist Patient 101, and it was not until the patient was placed in an ED bed and started breathing (agonal [gasping] type description) respirations, that the staff responded with seriousness.

The record for Patient 101 was reviewed. The record indicated Patient 101, a 79 year old female, presented to the ED via EMS (Emergency Medical Services [ambulance]) on November 28, 2013, with a chief complaint of sudden onset of a headache and a history of a brain aneurysm. According to the EMS record, upon their arrival to her home, the patient was holding her head in her hands, had sudden onset of a headache with pain 10/10 on a pain scale of 0-10 (10 being the worst pain), had nausea and vomiting, and had HTN (high blood pressure). The record indicated Patient 101's BP (blood pressure) was 204/100 (normal 120/80) upon EMS arrival to her house, they transported her to the hospital, and arrived there at 11:39 p.m.

The ED record indicated Patient 101 was moved from the ambulance gurney in the hallway to an ED bed at 56 minutes after midnight (one hour and 11 minutes after arrival), and seen by the ED physician. Physician orders were entered at 56 minutes after midnight that included a CT (computerized tomography) of the brain.

According to the ED record, "approximately five minutes," after Patient 101 was examined by the ED physician, she became unresponsive and required intubation (a tube placed through her mouth and into her trachea to provide an airway) and placement on a ventilator (a machine to assist with breathing).

At 1:07 a.m., a CT of the brain was reordered (using stroke protocol this time). The CT was performed at 1:30 a.m. (one hour and 45 minutes after arrival to the ED). The CT results were called back to the ED physician at 2:14 a.m. (44 minutes after the CT was done, and two hours and 29 minutes after Patient 101 arrived in the ED). The results indicated Patient 101 had a diffuse subarachnoid hemorrhage (bleeding in the brain from the aneurysm).

According to the ED record, Patient 101 had a BP of 190/68 at 1:30 a.m. (one hour and 24 minutes after arrival to the ED - the first BP taken by LN 2 after the patient was placed in an ED bed), Nipride (a medication given by continuous IV [intravenous] drip to lower the blood pressure) was started at 1:55 a.m. (40 minutes after intubating Patient 101, and two hours and 10 minutes after she arrived to the ED).

Patient 101 was transferred to another acute care facility for a higher level of care at 4:51 a.m., where she expired.

The physician examination of Patient 101 was delayed due to failure of ED staff to assume responsibility for her care while she remained in the EMS hallway.

b. During a tour of the ED on March 17, 2014, at 2:50 p.m., accompanied by the ED director, three ED beds were observed with no patients in them. The director stated the beds were empty but they could not put patients in them because the ED was, "short staffed," so four beds were, "closed." Two EMS gurneys were observed in the hallway near the ambulance entrance. Each gurney had a patient on it with EMS personnel standing by.

During an interview with the EMS personnel, both stated they were told the ED was short a nurse, so there were four beds closed. According to the EMS personnel, one patient had been waiting for a bed assignment for 45 minutes, with no staff monitoring the patient and no exam or evaluation by a physician. They stated this occurred, "about half the time," when they brought patients into the ED.

During a tour of the ED on March 17, 2014, at 9:30 p.m., three patients (two on gurneys and one in a wheelchair), including Patients 301 and 302, were observed in the back hall by the ambulance entrance. Each patient had two EMS personnel standing nearby.

In a concurrent interview with EMS 1, she stated Patient 301 was brought to the ED for further evaluation of a possible stroke. She stated Patient 301 was having difficulty putting sentences together, and had slurred speech. EMS 1 stated they had been at the ED for a little over an hour. She stated LN 10 had been over to triage Patient 301 after they arrived in the ED. She stated the physician had not seen the patient yet. EMS 1 stated she was responsible for Patient 301 until the facility was able to place the patient into a room.

On March 17, 2014, at 10:15 p.m., LN 10 was interviewed. LN 10 stated he triaged Patient 301 when the patient arrived to the ED. He stated he took vital signs and did a quick history on the patient. When asked if he was the Triage Nurse, he stated no, he just saw him there so he triaged him. LN 10 stated he was just a "floater" nurse. He stated that meant he was floating within the ED, and not assigned to any specific patients. He stated he was available to help the Charge Nurse or any other staff that needed help. He stated at 11 p.m., another nurse would be going home, and at that time he would start taking patient assignments. When asked why the patients from EMS providers were lined up in the hall, he stated there was no where to put them (although there were empty beds in the ED), but Patient 301 had just been assigned to a room, so he was in the process of moving him. LN 10 was not sure if there were any other empty beds at the time.

On March 18, 2014, the record for Patient 301 was reviewed. The EMS "Patient Care Report," indicated EMS was dispatched to Patient 301's home on March 17, 2014, at 7:30 p.m., for complaints of "Difficulty speaking." The report indicated the onset of symptoms was 45 minutes earlier. The medical record, "Triage Report," indicated Patient 301 arrived to the ED, via ambulance, on March 17, 2014 at 8:22 p.m., with complaints of slurred speech (one hour and 20 minutes after the onset of symptoms).

The "Daily Focus Assessment Report," indicated at 10:30 p.m., (when Patient 301 was placed in an ED bed) the patient was awaiting physician evaluation. Patient 301 was first seen by the physician at 10:39 p.m., at which time, "CT brain w/o [with out] Contrast Stroke Procedure," was ordered (two hours and 17 minutes after the patient arrived to the ED and three hours and 54 minutes after the onset of symptoms).

On March 20, 2014, at 9:35 a.m., LN 11 was interviewed. LN 11 stated if a patient presented to the ED with symptoms associated with a possible stroke, including slurred speech and difficulty speaking, then there was a stroke protocol that could be implemented immediately, even before the patient was seen by the physician. This would include getting the patient to radiology for a CT scan as quickly as possible, because early detection was important for course of treatment. LN 11 reviewed Patient 301's record and stated the standing orders should have been implemented for this patient when he first arrived to the ED and was triaged at 8:47 p.m. LN 11 verified that no diagnostic orders or monitoring were implemented until after the physician examined the patient exam at 10:39 p.m. (one hour and 52 minutes after triage).

A blank "ED Triage Standing Orders," was reviewed. There was an order set for "Suspected CVA" (Cerebral Vascular Accident - Stroke). The order set included, but was not limited to, blood tests, EKG, STAT CT of brain, oxygen and cardiac monitoring.

The physician examination of Patient 301 was delayed due to failure of ED staff to assume responsibility for her care while she remained in the EMS hallway.

c. In an interview with EMS 2, on March 17, 2014, at 9:40 p.m., he stated Patient 302 was brought to the ED with right hip pain following a fall. He stated Patient 302 was also in c-spine precautions (a cervical-neck brace placed on patients to maintain alignment of the cervical spine following a fall with possible injury) until it could be cleared by the doctor. EMS 2 stated he had been in the ED for about 15 minutes. He stated the ED CN (charge nurse) had been notified of Patient 302's arrival, but no assessment by the ED staff had been done yet. EMS 2 stated the ED CN reviewed Patient 302's vital signs that EMS took prior to arrival to the ED, but did not repeat them, and did not assess the patient at that time.

On March 18, 2014, the record for Patient 302 was reviewed. The "Triage Report," indicated Patient 302 arrived to the ED, via ambulance, on March 17, 2014 at 9:31 p.m. The triage/initial assessment time was 10:47 p.m. (when the patient was placed in an ED bed, and one hour and 16 minutes after arrival to ED), with complaints, per EMS, "Had 8 beers, became dizzy, fell slowly to the floor, no LOC [loss of consciousness] in C-spine." Patient 302 complained of pain to the right hip of 6/10. The physician examination was at done at 11:49 p.m. (two hours and 18 minutes after the patient arrived to the ED).

The record did not have documented evidence that Patient 302's pain level was reassessed until the following morning at 8:16 a.m., when he had pain of 10/10, (nine hours and 29 minutes after he complained of pain level 6/10).

(Pain is assessed by having the patient score their level of pain on a scale of 1-10, with 10 being the worst pain).

On March 20, 2014, at 9:35 a.m., LN 11 was interviewed. She stated, if a patient presented to the ED with symptoms associated with a possible hip fracture and/or moderate to severe pain, the physician should be notified in order to obtain an order for x-rays and pain medication. LN 11 reviewed Patient 302's record and stated the physician should have been notified of the patients pain level, and the patient should have been sent for x-rays.

A blank "ED Triage Standing Orders," was reviewed. There was an order set for "R/O [rule out] Fracture Hip" which included "X-ray appropriate hip/pelvis." In addition, there was an order set for "Pain Management" which included, "Moderate to severe pain: (4-10/10) Consult MD for order."

The physician examination of Patient 302 was delayed due to failure of ED staff to assume responsibility for her care while she remained in the EMS hallway.

d. The record for Patient 400 was reviewed on March 19 and 20, 2014. Patient 400, a 73 year old female, was brought to the ED on March 17, 2014, by paramedics. According to the EMS report, Patient 400 was found laying on the floor with severe tremors (shaking) throughout her body. Patient 400's skin assessment indicated "Hot Temperature." Patient 400 arrived at the facility at 10:05 a.m., and was triaged at 10:27 a.m.

The triage record indicated the patient's initial temperature was 105.6 degrees Fahrenheit (normal 98.6), her heart rate was 146 beats per minute (normal adult rates 60-100), and her respiratory rate was 28 per minute (normal 12-20). The triage note indicated Patient 400, "was found on the floor, altered, shaking, on arrival.

The record indicated Patient 400 was moved to an ED bed (from the ambulance gurney) at 10:45 a.m. (40 minutes after arriving in the ED). The assessment at that time indicated the patient was pale with garbled speech, she had an altered level of consciousness, she had a rapid and irregular pulse, and she was in severe distress.

Physician orders to treat the elevated temperature were received at 10:56 a.m., 48 minutes after her arrival in the ED.

The physician examination of Patient 400 was delayed due to failure of ED staff to assume responsibility for her care while she remained in the EMS hallway.

During an interview with the CNO (chief nursing officer) on March 17, 2014, at 10:05 p.m., the CNO stated when patients arrived to the ED by ambulance, they were the responsibility of the EMS personnel until the ED staff took them off of the EMS gurney and got report on the patient. She stated at that point, they became the facility's patients.

During an interview with the ED CN on March 17, 2014, at 11:10 p.m., the CN stated the ED staff did not monitor or take responsibility for patients who arrived by ambulance until they, "hit," the ED gurneys. He stated, "their gurney, their patient - my gurney, my patient."

On March 20, 2014, at 9:35 a.m., LN 11 was interviewed. LN 11 stated if a patient came to the ED via ambulance, then those patients were the responsibility of the EMS personnel, who was to "Keep one hand on the gurney at all times." She stated the patients would remain in the hall under the care and monitoring of EMS until such time the patient was placed in a room and a hand off report was given to the assigned nurse.



25937

3. a. During a tour of the ED on March 17, 2014, at 9:30 p.m., three patients (two on gurneys and one in a wheelchair), including Patient 302, were observed in the back hall by the ambulance entrance. Patient 302 had two EMS personnel standing nearby.

In a concurrent interview with EMS 2, he stated Patient 302 was brought to the ED with right hip pain following a fall. He stated Patient 302 was also in c-spine precautions (a cervical-neck brace placed on patients to maintain alignment of the cervical spine following a fall with possible injury) until it could be cleared by the doctor. EMS 2 stated he had been in the ED for about 15 minutes. He stated the ED CN had been notified of Patient 302's arrival, but no triage had been done yet. EMS 2 stated the ED CN reviewed Patient 302's vital signs that EMS took prior to arrival to the ED, but did not repeat them, and did not assess the patient's pain at that time.

(Pain is assessed by having the patient score their level of pain on a scale of 1-10, with 10 being the worst pain).

On March 18, 2014, the record for Patient 302 was reviewed. The "Triage Report," indicated Patient 302 arrived to the ED, via ambulance, on March 17, 2014 at 9:31 p.m. The triage time was 10:47 p.m., (when the patient was placed in an ED bed, and one hour and 16 minutes after arrival to ED), with complaints, per EMS, "Had 8 beers, became dizzy, fell slowly to the floor, no LOC [loss of consciousness] in C-spine." Patient 302 complained of pain to the right hip of 6/10. There was no indication the physician was notified of the pain level to the hip following a fall. Pain management was not implemented.

The record did not have documented evidence that Patient 302's pain level was reassessed until the following morning at 8:16 a.m., when he had pain of 10/10, (nine hours and 29 minutes after he first complained of pain).

On March 20, 2014, at 9:35 a.m., LN 11 was interviewed. She stated, if a patient presented to the ED with symptoms associated with a possible hip fracture and/or moderate to severe pain, the physician should be notified in order to obtain an order for x-rays and pain medication. LN 11 reviewed Patient 302's record and stated the physician should have been notified of the patients pain level, and the patient should have been sent for x-rays. LN 11 verified that Patient 302's pain level was not reassessed, and no pain medication was given, until the following morning, more than nine hours later.

A blank "ED Triage Standing Orders," was reviewed. There was an order set for "R/O [rule out] Fracture Hip" which included "X-ray appropriate hip/pelvis." In addition, there was an order set for "Pain Management" which included, "Moderate to severe pain: (4-10/10) Consult MD for order."

b. The record for Patient 304 was reviewed. Patient 304 arrived to the ED on January 10, 2014, at 6:07 a.m., with complaints of high potassium and left arm pain of 8/10. She was triaged at 6:24 a.m., and assigned an ESI level 4. There was no indication the physician was notified of the patient's pain level at that time.

There was a physician order, dated January 10, 2014, at 12:04 p.m., for Hydromorhone (pain medication) 1 mg intramuscular once, as needed for pain, STAT. The "Medication Administration Record," indicated the pain medication was given at 12:07 p.m. (5 hours and 43 minutes after the patient complained of severe pain).

The "Emergency Room Report," for Patient 304, indicated the patient had a history of end-stage renal (kidney) disease, and was on dialysis (a process of removing waste and excess water from the blood, used in people with renal failure). Diagnostic studies were done, and medication was given to treat high potassium and pain. Patient 304 was stable and released to dialysis, which the patient already had an appointment for.

The Daily Focus Assessment Report was reviewed. There was no documentation of a complete nursing assessment of the patient.

The Vital Sign Report, indicated vital signs were taken at 6:29 a.m., after the patient first arrived to the ED, and again at 1:20 p.m., right before discharge (5 hours and 51 minutes later). In addition, there was no documentation of pain re-assessment.

On March 11, 2014, at 9:35 a.m., LN 11 was interviewed. LN 11 stated after a patient was placed in a room, a complete nursing assessment was completed. LN 11 stated the patients were re-assessed, including vital signs taken, depending on the patients needs and ESI level. LN 11 reviewed Patient 304's record and was unable to find documentation of a nursing assessment. In addition, she stated there was no re-assessment of pain, and no other vital signs taken between admission and discharge. LN 11 stated Patient 304 had pain at the time of triage, and should have been reassessed. Also based on Patient 304's ESI, she should have had vital signs taken every 4 hours.

The facility policy and procedure titled, "Assessment of the Emergency Department Patient," dated February 2014, was reviewed. The policy indicated, " Full assessments should not be done in the triage area: only the information required to assign a triage level should be recorded. The primary nurse is responsible for completing the remaining assessment within 15 minutes of arrival to the patient's room... Patients should be reassessed at appropriate intervals... Progression of illness during the waiting period must be anticipated... additional vital signs shall be obtained depending on patient's condition..."

The facility policy and procedure titled, "Vital Signs- Standard of Care," dated December 2013, was reviewed. The policy indicated, "ESI Level 4: Vital signs every 4 hours."

c. The record for Patient 400 was reviewed on March 19-20, 2014. Patient 400, a 73 year old female, was brought to the facility's emergency department on March 17, 2014, by paramedics. According to the "Patient Care Report," Patient 400 was found laying on the floor with severe tremors (shaking) throughout her body. Patient 400's skin assessment indicated "Hot Temperature." Patient 400 arrived at the facility on March 17, 2014, at 10:05 a.m., and triage (assessment process) was conducted at 10:27 a.m.

Patient 400's "Triage Report," indicated the patient's initial temperature was 105.6 degrees Fahrenheit, and the patient's pulse was 146 beats per minute (normal adult rates 60-100), respiratory rate was 28 per minute and oxygen saturation rate of 94 %. The triage note, completed at 10:27 a.m., indicated the patient "was found on the floor, altered, shaking, on arrival..." Patient 400 was triaged as ESI level 3.

A review of the "Emergency Room Report," dated March 17, 2014, indicated Patient 400 was altered (mentation changes), shaking all over, and hot to touch. The record indicated the patient's blood pressure could not be taken due to the patient's shaking.

A review of the CPOE (Computerized Provider Order Entry) for Patient 400 on March 20, 2014, revealed orders for hourly vital signs and neuro checks starting at 10:56 a.m., on March 17, 2014. Additional orders indicated the following:

12:33 p.m., Tylenol per rectum;
1:29 p.m., vital signs every two hours; and
2:19 p.m., vital signs every one hour.

A review of the nursing documentation for Patient 400 revealed vital signs were taken at:

10:30 a.m. temp=105.6, P=146, RR=28; (there was no evidence the temperature reading was rechecked for error);
11:03 a.m. HR=123, RR=32;
11:30 a.m. HR=119, RR=29;
12 p.m. HR=95, RR 25;
12:30 p.m. HR=84; RR 28;
3 p.m. (2 hours and thirty minutes later) HR=81, RR=21;
3:19 p.m. temp 97.8, HR 77, RR 22; and
5:03 p.m. (one hour and 44 minutes later) HR= 82, RR 22.

Patient 400's vital signs were not monitored hourly between 12 p.m., and 5 p.m., as ordered by the physician. In addition, record review revealed the patient's temperature was not rechecked until 3:19 p.m., four hours and 49 minutes later.

The facility policy and procedure titled "Vital Signs - Standard of Care," with a last revised/reviewed date of December 2013, was reviewed. The policy indicated vital signs would be repeated if not within normal limits as follows " Temp: 96 to 101 degrees F: Pulse: 60-100 beats per minute. Respiration: 12-24 respirations per minute.

During an interview with LN 6 on March 20, 2014, at 11:30 a.m., LN 6 stated she was unable to find evidence in the record of hourly vital signs. LN 6 stated vital signs should be taken as ordered by the physician. In addition, LN 6 was unable to find documentation that Patient 400's temperature was rechecked prior to 3:19 p.m. LN 6 stated Patient 400's temperature should have been rechecked within a half hour of receiving the Tylenol.

d. The record for Patient 110 was reviewed on March 20, 2014. Patient 110, a 17 year old pregnant female, presented to the ED on March 18, 2014, at 53 minutes after midnight, with complaints of lower abdominal pain and vaginal bleeding. The triage report indicated her vital signs were assessed, but there was no assessment of her pain level. Patient 110 was assigned an ESI level three.

The ED record indicated her vital signs were reassessed at 1:02 a.m., and again at 8:03 a.m. There was no evidence in the record Patient 110's vital signs were reassessed for a seven hour period.

The facility policy titled, "Vital Signs - Standards of Care," was reviewed on March 20, 2014. The policy indicated for ESI level three, vital signs would be done every two hours unless ordered more frequently.

e. The record for Patient 121 was reviewed on March 20, 2014. Patient 121, a 65 year old female, presented to the ED on September 13, 2013, at 11:08 p.m., complaining of arm and elbow pain after a fall. The triage record indicated the patient's BP (blood pressure) was 200/92 (normal 120/80) and her pain was a 10/10, the highest level of pain. She was assigned an ESI level four.

The ED record indicated Patient 121 had her arm placed in a sling and was medicated for pain, then discharged from the ED at 2:11 a.m. (three hours and three minute

Based on interview and record review, the facility failed to ensure appropriate integration of emergency services and radiology services when;

1. The ED (emergency department) physicians failed to document their interpretation of x-rays taken after hours, when no radiologist was on site to perform the interpretation, for 25 of 34 x-ray procedures; and,

2. The ED physicians failed to document follow up on patients when the radiologist notified them there was a discrepancy (difference) in the radiologist interpretation and the ED physician interpretation, for six of seven patients who were discharged from the ED (Patients 108, 120, 124, 125, 126, and 127).

These failed practices resulted in the potential for patients to go without appropriate treatment for emergency conditions, and patient harm or death.

Findings:

The facility policy titled, "Radiology Requests - Handling," was reviewed on March 19, 2014. The policy indicated the following:

a. (After hours) X-ray exams done in the ED would be reviewed by the ED physician;

b. The ED physician would place a preliminary reading in the (radiology) computer system;

c. The radiologist would review the exams and provide an over read;

d. If there was a discrepancy, the radiologist would contact the ED and let them know about the discrepancy; and,

e. The ED would determine the course of action.

The facility policy for notification of patients regarding radiology results after discharge was reviewed on March 19, 2014. The policy indicated a radiology discrepancy would be reviewed by an ED provider, and necessary changes in treatment would be communicated to the patient.

1. During a tour of the radiology department on March 17, 2014, at 11:35 p.m., the RIS (radiology information system)/PACS (picture archiving and communications system) Specialist stated he was responsible for oversight of the after hours radiology process. The specialist explained the process worked as follows:

a. A radiologist was on site from 7 a.m. to 9 p.m. seven days a week;

b. After 9 p.m., the x-rays that were ordered by physicians in the ED were available to, and read by, the ED physicians to determine the appropriate treatment for the patient;

c. The ED physicians were responsible for entering their interpretation of the x-ray into the system so the radiologist would be able to see it;

d. When the radiologist came in the next morning, he/she would re-read the x-rays that had been interpreted by the ED physicians the previous night;

e. If there was a discrepancy, the radiologist would call the ED physician and let them know;

f. The radiologist would document their interpretation in the system (next to the ED physician interpretation); and,

g. The radiologist would dictate a, "final," reading/interpretation, including the phone call made to the ED physician.

The specialist stated he did not have a system in place to determine whether the process was effective in ensuring patients received the appropriate diagnosis and follow up care when necessary.

During an interview with Radiologist 1 on March 17, 2014, at 12 noon, the radiologist stated the ED physicians were, "terrible," in remembering to enter their interpretation of the x-ray into the system. He stated the ED physicians were supposed to do it, and they said they would, but they did not. The radiologist stated they (the radiologists) had told the RIS/PACS Specialist, "how terrible it is," but it did not change. He stated he could not rely on the system, so any time he was concerned about results he found, he would notify the ED.

A review of after hours x-rays performed on patients in the ED indicated the following:

a. On March 16, 2014, three of three x-rays had no interpretation documented by the ED physician;

b. On March 17, 2014, 14 of 19 x-rays had no interpretation documented by the ED physician; and,

c. On March 18, 2014, eight of 12 x-rays had no interpretation documented by the ED physician.

Without the ED physician interpretation of the x-ray, the radiologist was unable to determine if a discrepancy existed.

2. A review of radiology discrepancies for ED patients, and the corresponding medical records, indicated there was no evidence of record review or consideration of appropriateness of treatment for the following:

a. Patient 108 had a chest x-ray on November 1, 2013. The ED physician's interpretation was, "negative." The radiologist's interpretation was a left eighth rib fracture with no pneumothorax (punctured lung);

b. Patient 120 had a foot x-ray on August 10, 2013. The ED physician's interpretation was, "neg," (negative). The radiologist's interpretation was suspected fracture of the cuboid bone (in the foot);

c. Patient 124 had an x-ray of the lower spine on August 20, 2013. The ED physician's interpretation was, "DJD" (degenerative joint disease). The radiologist's interpretation was mild compression deformity (collapse) of the third lumbar (lower back) vertebra;

d. Patient 125 had an x-ray of the wrist on October 5, 2013. The ED physician's interpretation was, "No Fx (fracture) seen." The radiologist's interpretation was questionable small fracture along the dorsum (outside) of the wrist. Correlation with clinical studies was recommended with a complete wrist series if indicated clinically;

e. Patient 126 had an x-ray of the elbow on September 14, 2013. The ED physician's interpretation was, "Negative." The radiologist's interpretation was a possible foreign body versus fragments of a displaced fracture; and,

f. Patient 127 had abdominal x-rays on November 15, 2013. The ED physician's interpretation was, "no free air (indicating no hole in the bowel), non-specific bowel gas pattern (indicating no evidence of obstruction)." The radiologist's interpretation was cholelithiasis (gall stones).

There was no evidence the ED physician reviewed the record, considered whether the treatment provided in the ED was appropriate, or determined whether or not the patient needed to be contacted for a change in treatment.

Based on observation, interview, and record review, the facility failed to ensure the staffing plan for nursing and medical staff was adequate to meet the needs of the ED (Emergency Department) patients. When the ED staffing was adequate according to the plans developed, CNs (Charge Nurses) were closing beds, nurses and NPs/PAs (Nurse Practitioners/Physician Assistants) were responsible for large volumes of patients, and patients were experiencing delays in bed assignments and delays in care. This failed practice resulted in the potential for harm and death in patients presenting to the ED for care.

Findings:

The facility had a 29 bed ED and provided basic emergency services. The average daily census was 129 patients.

A review of the ED nurse staffing plan indicated, to be adequately staffed, the following was required:

a. 7 a.m. to 7 p.m. - 10 RNs (registered nurses);

b. 11 a.m. to 11 p.m. - three additional RNs and one LVN (licensed vocational nurses) or technician; and,

c. 7 p.m. to 7 a.m. - 10 RNs.

According to the plan, the ED needed 10 RNs at all times, with a total of 13 RNs and one LVN or technician between the hours of 11 a.m. and 11 p.m. to provide appropriate staffing to meet the needs of the patients.

The plan indicated this staffing would provide coverage for a CN, a triage nurse, the RME (rapid medical exam) area, and the 29 ED beds.

A review of the ED medical staffing plan indicated the following was required:

a. 6 a.m. to 4 p.m. - one physician;

a. 9 a.m. to 9 p.m. - one mid level provider (NP or PA);

c. 10 a.m. to 8 p.m. - one additional physician;

d. 3 p.m. to 3 a.m. - one additional mid level provider;

e. 4 p.m. to 2 a.m. - one additional physician; and,

f. 8 p.m. to 6 a.m. - one physician.

According to the plan, to meet the needs of the patients the ED needed one physician on at all times, with additional providers coming and going to total the following:

a. From 3 a.m. to 9 a.m. (six hours) there would be one physician in the department;

b. From 9 a.m. to 10 a.m. (one hour), there would be one physician and one mid level provider;

c. From 10 a.m. to 3 p.m. (five hours), there would be two physicians and one mid level provider;

d. From 3 p.m. to 9 p.m. (six hours), there would be two physicians and two mid level provider;

e. From 9 p.m. to 2 a.m. (five hours), there would be two physicians and one mid level provider; and,

f. From 2 a.m. to 3 a.m. (one hour), there would be one physician and one mid level provider.

1A. During a tour of the ED RME area on March 17, 2014, at 2:25 p.m., accompanied by the ED director, the RME area was observed with two gurneys and two chairs in an enclosed room with two doors (one leading to the lobby and one leading to the ED). The director stated the RME was staffed by ED nursing staff and mid level providers.

During a concurrent interview with LN (licensed nurse) 3 and LN 4 at 2:35 p.m., LN 3 stated the RME area was for rapid evaluation and treatment of patients that were triaged an ESI level three or higher. LN 3 stated they sometimes got ESI level two patients, and they started the workup while the patient was waiting to be placed in an ED bed. LN 3 stated they currently had one patient laying on a gurney who had abdominal pain, had been medicated for the pain, and was waiting for the medication to take effect. LN 3 stated the staffing in the RME at the time was three nurses and one PA. LN 3 stated all of the patients in the lobby and in the RME area belonged to the RME staff. She stated all of those patients were somewhere in the course of their evaluation or treatment (having been triaged, seen by the provider, had labs or x-rays taken, been given medication, or were waiting for discharge information/orders), and they had to be monitored by the RME nurses. She stated she did not know how many patients the staff was responsible for, and that she could not keep track of them all. She stated it was very, "chaotic."

LN 4 stated it was, "horrible." The LN stated the staff, "could not keep up."

A review of the ED tracking board (a computer screen that displayed the names and locations of all patients who had registered to be seen in the ED) indicated 31 patients were assigned to the lobby/RME area (meaning they were going through the RME process). The RME staff was responsible for 31 patients.

1B. During multiple observations of the ED RME and lobby area on March 17, 2014, between 9:10 p.m. and 11:30 p.m., the ED lobby remained full with patients and visitors coming and going.

During an interview with LN 5 on March 17, 2014, at 10:15 p.m., the LN stated the RME nursing staff was responsible for all of the patients who were going through the RME process. The LN stated it was not uncommon to have 30-40 patients being monitored by one or two nurses at night time. The LN stated she did not feel safe in her practice. The LN stated she did not feel that the patients were safe, and that, "something is going to happen."

A review of the assignments and the patient tracking board at 10:15 p.m. indicated there were two nurses and two PAs responsible for 31 patients in the RME process.

The following ED records were reviewed on March 20, 2014, for patients who were seen in the ED on March 17, 2014:

a. Patient 106, a 35 year old male, presented to the ED at 10:20 p.m. with complaints of having a seizure, and falling back and hitting his head. The record indicated the patient was triaged at 11:01 p.m. (41 minutes after arrival), assessed by the nurse in the RME (rapid medical exam) area at 26 minutes after midnight (two hours and six minutes after arrival), and left the ED at an undisclosed time (no time documented). There was no evidence Patient 106 was ever seen by a provider (physician or PA [physician's assistant]);

b. Patient 110, a 17 year old pregnant female, presented to the ED at 53 minutes after midnight, with lower abdominal pain and vaginal bleeding. The record indicated the patient was seen by the provider in the RME at 4:34 a.m. (three hours and 41 minutes after arriving at the ED);

c. Patient 111, a 60 year old female, presented to the ED at 5:03 p.m., with chest pain. There was no evidence in the record the patient was ever seen by a provider. The record indicated the patient left without being seen at 8 p.m. (two hours and 57 minutes after arriving at the ED).

d. Patient 112, a nine year old female, presented to the ED at 8:58 p.m., complaining of an asthma attack. The record indicated the patient was seen by a provider in the RME at five minutes after midnight (three hours and seven minutes after arriving at the ED);

e. Patient 113, a six year old female, presented to the ED at 8:53 p.m., with complaints of dental pain. The record indicated the patient was seen by a provider in the RME at 11:29 p.m. (two hours and 36 minutes after arriving at the ED);

f. Patient 114, a 79 year old male, presented to the ED at 6:02 p.m., with complaints of post operative bleeding. The record indicated the patient was seen by a provider in the RME at 9:15 p.m. (three hours and thirteen minutes after arriving at the ED);

g. Patient 115, a 28 year old male, presented to the ED at 8:48 p.m., with a laceration on his arm. The record indicated the patient was seen by the provider in the RME at 1 a.m. (three hours and 12 minutes after arriving at the ED);

h. Patient 116, a 25 year old male, presented to the ED at 8:29 p.m. following a motor vehicle accident. The record indicated the patient was seen by a provider in the RME at 11:43 p.m. (three hours and 14 minutes after arriving at the ED);

i. Patient 117, a 13 year old male, presented to the ED at 8:19 p.m., with an earache. The record indicated the patient was seen by a provider in the RME at 11:50 p.m. (three hours and 31 minutes after arrival at the ED);

j. Patient 118, a two year old female, presented to the ED at 8:08 p.m., with complaints of a head injury. There was no evidence in the record Patient 118 was ever seen by a provider. The record indicated the patient left without being seen at 10:25 p.m. (two hours and 17 minutes after arriving at the ED); and,

k. Patient 119, a 24 year old female, presented to the ED at 8:06 p.m., complaining of back pain. The record indicated the patient was seen by a provider in the RME at 40 minutes after midnight (four hours and 34 minutes after arriving at the ED).

2A. During a tour of the ED on March 17, 2014, at 2:50 p.m., accompanied by the ED director, three ED beds were observed with no patients in them. The director stated the beds were empty but they could not put patients in them because the ED was, "short staffed," so four beds were, "closed." Two EMS gurneys were observed in the hallway near the ambulance entrance. Each gurney had a patient on it with EMS (Emergency Medical Services) personnel standing by.

During an interview with the EMS personnel, both stated they were told the ED was short a nurse, so there were four beds closed. According to the EMS personnel, one patient had been waiting for a bed assignment for 45 minutes, with no staff monitoring the patient and no exam or evaluation by a physician. They stated this occurred, "about half the time," when they brought patients into the ED.

A review of the current ED staffing (day shift) indicated there were 14 nurses on duty, 11 nurses working 7 a.m. to 7 p.m., and three nurses working 11 a.m. to 11 p.m. (one more nurse than required according to their staffing plan).

2B. During a tour of the ED on March 17, 2014, at 9:30 p.m., three patients (two on gurneys and one in a wheelchair), including Patients 301 and 302, were observed in the back hall by the ambulance entrance. Each patient had two EMS personnel standing nearby.

In an interview with EMS 1 on March 17, 2014, at 9:40 p.m., she stated Patient 301 was brought to the ED for further evaluation of a possible stroke. She stated Patient 301 was having difficulty putting sentences together, and had slurred speech. EMS 1 stated they had been at the ED for a little over an hour. She stated LN 10 had been over to triage Patient 301 after they arrived in the ED. She stated the physician had not seen the patient yet. EMS 1 stated she was responsible for Patient 301 until the facility was able to place the patient into a room.

In a concurrent interview with EMS 2, he stated Patient 302 was brought to the ED with right hip pain following a fall. He stated Patient 302 was also in c-spine precautions (a cervical-neck brace placed on patients to maintain alignment of the cervical spine following a fall with possible injury) until it could be cleared by the doctor. EMS 2 stated he had been in the ED for about 15 minutes. He stated the ED CN (charge nurse) had been notified of Patient 302's arrival, but no assessment by the ED staff had been done yet. EMS 2 stated the ED CN reviewed Patient 302's vital signs that EMS took prior to arrival to the ED, but did not repeat them, and did not assess the patient at that time.


On March 17, 2014, at 10:15 p.m., LN 10 was interviewed. LN 10 stated he triaged Patient 301 when the patient arrived to the ED. He stated he took vital signs and did a quick history on the patient. When asked if he was the Triage Nurse, he stated no, he just saw him there so he triaged him. LN 10 stated he was just a "floater" nurse. He stated that meant he was floating within the ED, and not assigned to any specific patients. He stated he was available to help the Charge Nurse or any other staff that needed help. He stated at 11 p.m., another nurse would be going home, and at that time he would start taking patient assignments. When asked why the patients from EMS providers were lined up in the hall, he stated there was no where to put them (although there were empty beds in the ED).

During an interview with the CNO (chief nursing officer) on March 17, 2014, at 10:05 p.m., the CNO stated when patients arrived to the ED by ambulance, they were the responsibility of the EMS personnel until the ED staff took them off of the EMS gurney and got report on the patient. She stated at that point, they became the facility's patients.

During an interview with the ED CN on March 17, 2014, at 11:10 p.m., the CN stated the ED staff did not monitor or take responsibility for patients who arrived by ambulance until they, "hit," the ED gurneys. He stated, "their gurney, their patient - my gurney, my patient."

On March 20, 2014, at 9:35 a.m., LN 11 was interviewed. LN 11 stated if a patient came to the ED via ambulance, then those patients were the responsibility of the EMS personnel, who was to "Keep one hand on the gurney at all times." She stated the patients would remain in the hall under the care and monitoring of EMS until such time the patient was placed in a room and a hand off report was given to the assigned nurse.

A review of the current ED staffing (night shift) indicated there were 13 nurses on duty, 11 nurses working 7 p.m. to 7 a.m., and two nurses working until 11 p.m. (one more than required according to their staffing plan).

The following records were reviewed for patients who arrived by ambulance on March 17, 2014:

a. The record for Patient 301 was reviewed on March 18, 2014. The EMS "Patient Care Report," indicated EMS was dispatched to Patient 301's home on March 17, 2014, at 7:30 p.m., for complaints of "Difficulty speaking." The report indicated the onset of symptoms was 45 minutes earlier. The medical record, "Triage Report," indicated Patient 301 arrived to the ED, via ambulance, on March 17, 2014 at 8:22 p.m., with complaints of slurred speech (one hour and 20 minutes after the onset of symptoms).

The "Daily Focus Assessment Report," indicated at 10:30 p.m., (when Patient 301 was placed in an ED bed) the patient was awaiting physician evaluation. Patient 301 was first seen by the physician at 10:39 p.m., at which time, "CT brain w/o [with out] Contrast Stroke Procedure," was ordered (two hours and 17 minutes after the patient arrived to the ED and three hours and 54 minutes after the onset of symptoms).

The physician examination of Patient 301 was delayed due to failure of ED staff to assume responsibility for her care while she remained in the EMS hallway, with staff stating there were no beds. The staffing was appropriate according to the facility plan, and a nurse was, " floating, " to help other nurses.

b. The record for Patient 302 was reviewed on March 18, 2014. The "Triage Report," indicated Patient 302 arrived to the ED, via ambulance, on March 17, 2014, at 9:31 p.m. The triage/initial assessment time was 10:47 p.m. (when the patient was placed in an ED bed, and one hour and 16 minutes after arrival to ED), with complaints, per EMS, "Had 8 beers, became dizzy, fell slowly to the floor, no LOC [loss of consciousness] in C-spine." Patient 302 complained of pain to the right hip of 6/10. The physician examination was at done at 11:49 p.m. (two hours and 18 minutes after the patient arrived to the ED).

The physician examination of Patient 302 was delayed due to failure of ED staff to assume responsibility for her care while she remained in the EMS hallway, with staff stating there were no beds. The staffing was appropriate according to the facility plan, and a nurse was, "floating," to help other nurses.

c. The record for Patient 400 was reviewed on March 19 and 20, 2014. Patient 400, a 73 year old female, was brought to the ED on March 17, 2014, by paramedics. According to the EMS report, Patient 400 was found laying on the floor with severe tremors (shaking) throughout her body. Patient 400's skin assessment indicated, "Hot Temperature." Patient 400 arrived at the facility at 10:05 a.m., and was triaged at 10:27 a.m.

The triage record indicated the patient's initial temperature was 105.6 degrees Fahrenheit (normal 98.6), her heart rate was 146 beats per minute (normal adult rates 60-100), and her respiratory rate was 28 per minute (normal 12-20). The triage note indicated Patient 400, "was found on the floor, altered, shaking, on arrival.

The record indicated Patient 400 was moved to an ED bed (from the ambulance gurney) at 10:45 a.m. (40 minutes after arriving in the ED). The assessment at that time indicated the patient was pale with garbled speech, she had an altered level of consciousness, she had a rapid and irregular pulse, and she was in severe distress.

Physician orders to treat the elevated temperature were received at 10:56 a.m., 48 minutes after her arrival in the ED.

The physician examination of Patient 400 was delayed due to failure of ED staff to assume responsibility for her care while she remained in the EMS hallway, with staff stating there were no beds. The staffing was appropriate according to the facility plan, and a nurse was, "floating," to help other nurses.

Although the number of staff was in compliance with the staffing plan, the ED staff did not meet the needs of the ED patients as evidenced by the following:

a. Multiple ED beds being, "closed," due to staffing, while a nurse with no patient assignment was available;

b. Delays in placing ambulance patients in ED beds and starting a medical screening exam due to staffing;

c. Delays in treating patients arriving by ambulance due to staffing;

d. RME nursing staff with assignments of one nurse to 10 to 15 patients;

e. RME provider staff with assignments of one provider to 15 to 31 patients; and,

f. Delays in examination and treatment of patients determined to be appropriate for the RME area.

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

1. Restraints were utililzed safely for one emergency department (ED) patient placed in restraints (Patient 207) when the staff left the patient alone after applying bilateral ankle restraints. The restraints were left in place when the absence of patient behaviors might have warranted the removal of the restraint. In addition, the ED nurse did not monitor the patient's condition while she was in restraints. This failed practice resulted in the potential for emotional and physical harm and death; and,

2. Four of four patients identified as a danger to themselves or others (Patients 204, 205, 206, and 207) received constant monitoring and supervision from facility staff in accordance with the facility policy. This failed practice resulted in the potential for the patients to cause injury or death to themselves, other patients, staff, or visitors in the ED.

Findings:

1. During a tour of the ED on March 17, 2014, at 9:20 p.m., a facility employee was observed sitting in the hallway by a patient room. The employee stated she was a sitter, assigned to monitor two patients who were placed on 5150 holds (involuntary psychiatric hold for persons who are a danger to self, others, or gravely disabled). The sitter stated one of the patients monitored was Patient 207, who was down the hall. The sitter stated Patient 207 was aggressive when she first arrived, but she was now sleeping, "With two restraints on," so Patient 207, "Should be OK."

On March 17, 2014, at 9:21 p.m., Patient 207 was observed laying in bed, sleeping soundly, with bilateral (both sides) soft ankle restraints in place, which were tied to the bed frame. There was no evidence of any other restraints.

On March 17, 2014, at 9:15 p.m., Security Officer 1 was asked to assist in observing Patient 207's restraints. The officer pulled back the blanket covering Patient 207 and exposed bilateral soft ankle restraints that were tied to the bed frame. No other restraints were observed. The officer visualized the restraints and stated only the patient's ankles were tied. The officer stated the patient did not have restraints applied anywhere else. The officer covered the patient and left the room. Patient 207 slept soundly, without moving or waking up, during this interaction.

On March 17, 2014, at 9:30 p.m., the ED CN (charge nurse) was asked to assist in observing Patient 207's restraints. The CN pulled back the blanket covering Patient 207 and exposed bilateral soft ankle restraints that were tied to the bed frame. No other restraints were observed. The CN stated only the patient's ankles were tied and Patient 207 did not have restraints anywhere else. The CN covered the patient and left the room. Patient 207 slept soundly, without moving or waking up, during this interaction.

During an interview with LN 1 (the nurse caring for Patient 207), the LN stated the patient had bilateral wrist and bilateral ankle restraints on when she got to the ED, and was dirty, so the LN, "Cleaned her up." The LN stated she did not know if there was an order for the restraints. The LN stated, after cleaning the patient, she medicated her (with a medication for agitation) and removed the wrist restraints. LN 1 stated, when she administered the medication (by injection into the leg muscle), the patient started kicking, so her ankles "stayed tied." LN 1 stated she did not know if the restraints were still on her patient. The LN stated she did not know if "they" removed them (she defined "they" as security). The LN stated Patient 207 did not need the restraints anymore because she was calm. She stated, "If they are still on, I will take them off."

The record for Patient 207 was reviewed on March 19, 2014. Patient 207, a 67 year old female, was taken to the ED by ambulance on March 17, 2014, after an overdose of medication. The record indicated the patient was agitated on arrival to the ED, and became calm after medication was administered. The record included a physician's order for bilateral soft wrist restraints and bilateral soft ankle restraints. There was no evidence in the record of the ED nurse monitoring the patient's restraints.

Although the patient was not exhibiting behaviors that warranted the use of restraints and the nurse stated the patient did not need to be restrained, Patient 207 remained in bilateral ankle restraints.

The facility policy titled, "Restraint and Seclusion," was reviewed on March 19, 2014. The policy indicated assessments would be completed by the LN as often as indicated by the patient's condition, behavior, and environmental consideration and at least every two hours.

2. During a tour of the ED on March 17, 2014, at 9:20 p.m., a staff member (Sitter 1) was observed in the hallway, outside of a four bed area where Patient 204 was resting on a gurney.

During an interview with Sitter 1 on March 17, 2014, at 9:20 p.m., she stated she was a sitter for two different patients (Patient 204 and 207) at the same time, who were both on 5150 holds (involuntary psychiatric hold for persons who are a danger to self, others, or gravely disabled). Sitter 1 stated Patient 207 was located across and down the hall from Patient 204. Sitter 1 stated she was not able to fully visualize Patient 207 while she was seated near Patient 204's room, but she would frequently walk over to see how Patient 207 was doing. Sitter 1 further stated Patient 207 was very agitated and aggressive when the patient first arrived at the ED, but now Patient 207 was sleeping, "with two restraints on," so Patient 207, "should be ok."

Patient 207 was observed on March 17, 2014, at 9:21 p.m., located across the hall approximately 15 feet down (past the nurse's station) from Patient 204. Patient 207 was resting in bed, with bilateral soft ankle restraints in place, tied to the bed frame.

During a second interview with Sitter 1 on March 17, 2014 at 9:45 p.m., she stated she received a third patient (Patient 205) to observe. The sitter stated Patient 205 was also on a 5150 hold. She stated Patient 205 was located in the room across from Patient 207. Sitter 1 stated she was waiting for staff to move all three patients into the same area so she could visualize them at the same time, instead going back and forth from room to room. Sitter 1 stated the three patients could not be moved until some of the other patients on the unit were discharged.

On March 17, 2014, at 9:45 p.m., Patient 205 was observed on a gurney in a room across the hall from Patient 207. Patient 205 was resting on the gurney with the privacy curtain closed around the gurney.

During a third interview with Sitter 1 on March 17, 2014, at 11:40 p.m., the sitter stated she had just received a fourth patient (Patient 206) who was also a 5150 hold. Sitter 1 stated Patient 206 was located in the same room on a gurney next to Patient 205. Sitter 1 stated she would frequently get up and check on each patient, but she was not able to fully visualize each patient due to the patients being in different proximities from each other. When Sitter 1 was asked if she ever had to be a sitter for more than four patients at one time she stated, "Occasionally, and when that happens the security officer helps me watch the other patients until the number comes back down to only four patients."

On March 17, 2014, at 11:40 p.m., Patient 206 was observed in the same room on a gurney next to Patient 205. Patient 206 was resting on the gurney and had the privacy curtain closed around the gurney.

a. The record for Patient 204 was reviewed. Patient 204 presented to the ED after an attempted suicide. The record indicated patient 204 was, "at imminent risk to self,".

b. The record for Patient 207 was reviewed. Patient 207 presented to the ED after an attempted suicide.

c. The record for Patient 205 was reviewed. Patient 205 presented to the ED after an attempted suicide.

d. The record for Patient 206 was reviewed. Patient 206 presented to the ED after a drug overdose, and was being treated for severe depression.

The facility policy titled, "Sitters,"

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

1. Four of five ED (emergency department) patients who arrived by ambulance were triaged appropriately (assigned a level of severity [ESI] consistent with their illness or injury) when they were assigned ESI levels of three instead of two (Patients 101, 301, 302, and 400). This failed practice resulted in delays in providing a timely and appropriate MSE (medical screening examination) for the purposes of determining whether an emergency medical condition existed;

2. Four of four ED patients arriving by ambulance were received by the ED staff in a manner consistent with standards of practice for accepting report on ED patients, when the ED staff did not assume care of them until they were removed from the ambulance gurney and placed in an ED bed (Patients 101, 301, 302, and 400). This failed practice resulted in delays in treating patients with serious injury or illness, and delay in allowing EMS (Emergency Medical Service) personnel to return to provide any needed emergency services to the community;

3. Vital signs, pain levels, and response to interventions were reassessed for five of 20 patients reviewed (Patients 302, 304, 400, 110, and 121). This failed practice resulted in the potential for unrecognized deterioration in patient's conditions, and the inability to determine if interventions were effective and patients were discharged safely;

4. 14 of 16 patients determined to be appropriate for treatment in the RME (rapid medical evaluation) area were seen by a provider within 30 minutes of arrival in accordance with Governing Body recommendations (Patients 106, 108, 110, 111, 112, 113, 114, 115, 116, 117, 118, 119, 120, and 121). This failed practice resulted in delays in assessment and treatment of patients in the RME area;

5. Medication administration was documented for one of one patient who was administered an anti anxiety medication (Patient 303), resulting in the potential for overmedication of the patient;

6. Appropriate integration of emergency services and radiology services, resulting in the potential for patients to go without appropriate treatment for emergency conditions, and patient harm or death (A1103); and,

7. The staffing plan for nursing and medical staff was adequate to meet the needs of the ED (Emergency Department) patients, resulting in the potential for harm and death in patients presenting to the ED for care (A1112).

The cumulative effect of these systemic problems resulted in failure to ensure emergency services were provided in a safe and effective manner to meet the needs of the patients and the community.

Findings:

1. The ESI (Emergency Severity Index) is a five level tool used by nurses to triage patients in the ED (Emergency Department). Patient acuity (severity of illness or injury) is rated from level one (most urgent and requiring immediate evaluation and treatment) to level five (least urgent and requiring the least amount of resources to evaluate and treat the patient).

ESI guidelines for the facility indicated ESI levels corresponded with patient acuity as follows:

ESI Level One (Resuscitation) - Patient requires immediate life saving intervention. When ESI Level One condition is identified, the triage process stops, the patient is taken directly to a room, and immediate physician intervention is requested;

ESI Level Two (Emergent) - The patient presents with a condition posing a potential threat to life, limb, or function and requires rapid medical intervention. These include high risk situations. Patients who might fall into level two are those with heart rate, respiratory rate or oxygen saturation rate in the danger zone. Danger zone vitals signs for adult are a heart rate greater than 100, respiratory rate greater than 20 and an oxygen saturation rate less than 92 %. When ESI Level Two condition is identified, the triage process stops, the patient is taken directly to a room, and immediate physician intervention is requested;

ESI Level Three (Urgent) - The patient presents with a condition that could progress to a serious problem. The presenting condition is anticipated to require utilization of two or more resources (lab, radiology, EKG, respiratory, etc.); and,

ESI Level Four (Semi Urgent) - The patient presents with a condition that has a low potential for deterioration or complications. One resource is expected to treat this patient.

a. During an interview with the family member of Patient 101 on January 9, 2014, at 4:30 p.m., the family member stated the patient was taken to the facility by ambulance the night of November 28, 2013, with a complaint of severe head pain. The family member stated Patient 101 had a brain aneurysm in the past, and this felt just like the other aneurysm. The family member stated when she arrived at the facility, she entered the ED to visit Patient 101, and saw her in the hallway on an ambulance gurney, where she stayed for, "about one hour," before she was moved to an ED bed. The family member stated the ED staff did not seem to be in a hurry to assist Patient 101, and it was not until the patient was placed in an ED bed and started breathing (agonal [gasping] type description) respirations, that the staff responded with seriousness.

The record for Patient 101 was reviewed. The record indicated Patient 101, a 79 year old female, presented to the ED via EMS (Emergency Medical Services [ambulance]) on November 28, 2013, with a chief complaint of sudden onset of a headache and a history of a brain aneurysm. According to the EMS record, upon their arrival to her home, the patient was holding her head in her hands, had sudden onset of a headache with pain 10/10 on a pain scale of 0-10 (10 being the worst pain), had nausea and vomiting, and had HTN (high blood pressure). The record indicated Patient 101's BP (blood pressure) was 204/100 (normal 120/80) upon EMS arrival to her house, they transported her to the hospital, and arrived there at 11:39 p.m.

The ED record indicated Patient 101 arrived at 11:45 p.m., and was triaged by LN (licensed nurse) 2 at six minutes after midnight (21 minutes after arrival to the ED). The record indicated Patient 101 had a history of a brain aneurysm, was complaining of a headache (10/10 on the pain scale), had a BP of 204/100 (the same BP obtained by the EMS personnel), and was restless. Patient 101 was assigned an ESI of three (urgent).

During an interview with the ED director on January 23, 2014, the director stated the condition Patient 101 presented to the ED with should have been assigned an ESI level two (with the physician being notified immediately), not a level three.

During an interview with the CNO on March 18, 2014, at 11:50 a.m., the CNO stated during the facility investigation into the care of Patient 101, LN 2 indicated she used the vital signs (including BP) taken by EMS prior to arrival at the ED for her triage vital signs. LN 2 indicated she did not retake the vital signs on arrival. LN 2 further indicated Patient 101 stayed on an ambulance gurney until she was moved to an ED bed (about one hour later), and she was not seen by a physician during that time.

Patient 101 was not triaged in compliance with the facility policy (should have been an ESI level two).

b. On March 18, 2014, the record for Patient 301 was reviewed. The EMS "Patient Care Report," indicated EMS was dispatched to Patient 301's home on March 17, 2014, at 7:30 p.m., for complaints of "Difficulty speaking." The report indicated the onset of symptoms was 45 minutes earlier. The medical record, "Triage Report," indicated Patient 301 arrived to the ED, via ambulance, on March 17, 2014 at 8:22 p.m., with complaints of slurred speech (one hour and 20 minutes after the onset of symptoms). The triage time was at 8:47 p.m., by LN 10. Patient 301 was assigned a ESI level 3 (Urgent).

Patient 301 was not triaged in compliance with the facility policy (should have been an ESI level two).

c. On March 18, 2014, the record for Patient 302 was reviewed. The "Triage Report," indicated Patient 302 arrived to the ED, via ambulance,

Based on observation, interview, and record review, the facility failed to ensure the staffing plan for nursing and medical staff was adequate to meet the needs of the ED (Emergency Department) patients. When the ED staffing was adequate according to the plans developed, CNs (Charge Nurses) were closing beds, nurses and NPs/PAs (Nurse Practitioners/Physician Assistants) were responsible for large volumes of patients, and patients were experiencing delays in bed assignments and delays in care. This failed practice resulted in the potential for harm and death in patients presenting to the ED for care.

Findings:

The facility had a 29 bed ED and provided basic emergency services. The average daily census was 129 patients.

A review of the ED nurse staffing plan indicated, to be adequately staffed, the following was required:

a. 7 a.m. to 7 p.m. - 10 RNs (registered nurses);

b. 11 a.m. to 11 p.m. - three additional RNs and one LVN (licensed vocational nurses) or technician; and,

c. 7 p.m. to 7 a.m. - 10 RNs.

According to the plan, the ED needed 10 RNs at all times, with a total of 13 RNs and one LVN or technician between the hours of 11 a.m. and 11 p.m. to provide appropriate staffing to meet the needs of the patients.

The plan indicated this staffing would provide coverage for a CN, a triage nurse, the RME (rapid medical exam) area, and the 29 ED beds.

A review of the ED medical staffing plan indicated the following was required:

a. 6 a.m. to 4 p.m. - one physician;

a. 9 a.m. to 9 p.m. - one mid level provider (NP or PA);

c. 10 a.m. to 8 p.m. - one additional physician;

d. 3 p.m. to 3 a.m. - one additional mid level provider;

e. 4 p.m. to 2 a.m. - one additional physician; and,

f. 8 p.m. to 6 a.m. - one physician.

According to the plan, to meet the needs of the patients the ED needed one physician on at all times, with additional providers coming and going to total the following:

a. From 3 a.m. to 9 a.m. (six hours) there would be one physician in the department;

b. From 9 a.m. to 10 a.m. (one hour), there would be one physician and one mid level provider;

c. From 10 a.m. to 3 p.m. (five hours), there would be two physicians and one mid level provider;

d. From 3 p.m. to 9 p.m. (six hours), there would be two physicians and two mid level provider;

e. From 9 p.m. to 2 a.m. (five hours), there would be two physicians and one mid level provider; and,

f. From 2 a.m. to 3 a.m. (one hour), there would be one physician and one mid level provider.

1A. During a tour of the ED RME area on March 17, 2014, at 2:25 p.m., accompanied by the ED director, the RME area was observed with two gurneys and two chairs in an enclosed room with two doors (one leading to the lobby and one leading to the ED). The director stated the RME was staffed by ED nursing staff and mid level providers.

During a concurrent interview with LN (licensed nurse) 3 and LN 4 at 2:35 p.m., LN 3 stated the RME area was for rapid evaluation and treatment of patients that were triaged an ESI level three or higher. LN 3 stated they sometimes got ESI level two patients, and they started the workup while the patient was waiting to be placed in an ED bed. LN 3 stated they currently had one patient laying on a gurney who had abdominal pain, had been medicated for the pain, and was waiting for the medication to take effect. LN 3 stated the staffing in the RME at the time was three nurses and one PA. LN 3 stated all of the patients in the lobby and in the RME area belonged to the RME staff. She stated all of those patients were somewhere in the course of their evaluation or treatment (having been triaged, seen by the provider, had labs or x-rays taken, been given medication, or were waiting for discharge information/orders), and they had to be monitored by the RME nurses. She stated she did not know how many patients the staff was responsible for, and that she could not keep track of them all. She stated it was very, "chaotic."

LN 4 stated it was, "horrible." The LN stated the staff, "could not keep up."

A review of the ED tracking board (a computer screen that displayed the names and locations of all patients who had registered to be seen in the ED) indicated 31 patients were assigned to the lobby/RME area (meaning they were going through the RME process). The RME staff was responsible for 31 patients.

1B. During multiple observations of the ED RME and lobby area on March 17, 2014, between 9:10 p.m. and 11:30 p.m., the ED lobby remained full with patients and visitors coming and going.

During an interview with LN 5 on March 17, 2014, at 10:15 p.m., the LN stated the RME nursing staff was responsible for all of the patients who were going through the RME process. The LN stated it was not uncommon to have 30-40 patients being monitored by one or two nurses at night time. The LN stated she did not feel safe in her practice. The LN stated she did not feel that the patients were safe, and that, "something is going to happen."

A review of the assignments and the patient tracking board at 10:15 p.m. indicated there were two nurses and two PAs responsible for 31 patients in the RME process.

The following ED records were reviewed on March 20, 2014, for patients who were seen in the ED on March 17, 2014:

a. Patient 106, a 35 year old male, presented to the ED at 10:20 p.m. with complaints of having a seizure, and falling back and hitting his head. The record indicated the patient was triaged at 11:01 p.m. (41 minutes after arrival), assessed by the nurse in the RME (rapid medical exam) area at 26 minutes after midnight (two hours and six minutes after arrival), and left the ED at an undisclosed time (no time documented). There was no evidence Patient 106 was ever seen by a provider (physician or PA [physician's assistant]);

b. Patient 110, a 17 year old pregnant female, presented to the ED at 53 minutes after midnight, with lower abdominal pain and vaginal bleeding. The record indicated the patient was seen by the provider in the RME at 4:34 a.m. (three hours and 41 minutes after arriving at the ED);

c. Patient 111, a 60 year old female, presented to the ED at 5:03 p.m., with chest pain. There was no evidence in the record the patient was ever seen by a provider. The record indicated the patient left without being seen at 8 p.m. (two hours and 57 minutes after arriving at the ED).

d. Patient 112, a nine year old female, presented to the ED at 8:58 p.m., complaining of an asthma attack. The record indicated the patient was seen by a provider in the RME at five minutes after midnight (three hours and seven minutes after arriving at the ED);

e. Patient 113, a six year old female, presented to the ED at 8:53 p.m., with complaints of dental pain. The record indicated the patient was seen by a provider in the RME at 11:29 p.m. (two hours and 36 minutes after arriving at the ED);

f. Patient 114, a 79 year old male, presented to the ED at 6:02 p.m., with complaints of post operative bleeding. The record indicated the patient was seen by a provider in the RME at 9:15 p.m. (three hours and thirteen minutes after arriving at the ED);

g. Patient 115, a 28 year old male, presented to the ED at 8:48 p.m., with a laceration on his arm. The record indicated the patient was seen by the provider in the RME at 1 a.m. (three hours and 12 minutes after arriving at the ED);

h. Patient 116, a 25 year old male, presented to the ED at 8:29 p.m. following a motor vehicle accident. The record indicated the patient was seen by a provider in the RME at 11:43 p.m. (three hours and 14 minutes after arriving at the ED);

i. Patient 117, a 13 year old male, presented to the ED at 8:19 p.m., with an earache. The record indicated the patient was seen by a provider in the RME at 11:50 p.m. (three hours and 31 minutes after arrival at the ED);

j. Patient 118, a two year old female, presented to the ED at 8:08 p.m., with complaints of a head injury. There was no evidence in the record Patient 118 was ever seen by a provider. The record indicated the patient left without being seen at 10:25 p.m. (two hours and 17 minutes after arriving at the ED); and,

k. Patient 119,