HospitalInspections.org

Based on interview and record review, the facility failed to ensure that the Condition of Participation of Nursing Services was met as evidenced by:

1. The registered nurse in the Emergency Department (ED) assigned to a patient failed to evaluate and oversee a patient's care according to facility's policies and procedures for one (1) of thirty (30) sampled patients (Patient 1). (Refer to A-0395).

2. The facility emergency room nursing staff failed to ensure licensed nurses assessed the patient every four hours according to facility's policies and procedures regarding patient care in the emergency department for one (1) of thirty sampled patients (Patient 1). (Refer to A-0398)

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

Based on interview and record review, the registered nurse in the Emergency Department (ED) assigned to a patient failed to evaluate and oversee a patient's care according to facility's policies and procedures for one (1) of thirty (30) sampled patients (Patient 1). Patient 1 had elevated blood pressure (a normal blood pressure [BP] range 90/60 millimeter of mercury [mmHg, a unit or measurement] to 120/ 80 mmHg) and was not checked every four hours.

This deficient practice resulted in Patient 1's elevated blood pressure with no physician notification, no treatment interventions, or reevaluation by the nurse providing care.

The deficient practice had the potential for other patients in the emergency department not receiving proper medical care.

Findings:

A review of Patient 1's Patient Summary Report, undated, indicated Patient 1 presented to the facility's emergency department (ED) on 12/14/2020 at 11:12 AM.

A review of Patient 1's Triage Noted, dated 12/14/2020 at 12:14 PM, indicated, Patient 1 was triaged as emergency severity index 3 ([ESI] is a five-level emergency department (ED) triage algorithm classifying patients into five groups from 1 [most urgent] to 5 [least urgent] based on patient ' s presenting health care problems and the number of resources their care might require) with a chief complaint of not feeling well.

On 10/5/2023, at 9:16 AM, during concurrent interview with the Clinical Operations Administrator (COA) and record review of Patient 1's Triage Note, dated 12/14/2020, at 12:14 PM, the COA stated Patient 1 had vital signs (V/S, a measurement of the body's essential physiological functions that includes pulse rate, temperature, respiratory rate and blood pressure) taken during triage in the ED. Patient 1's ED triage vitals taken at 12:14 PM indicated high blood pressure at 186/114 millimeter of mercury (mmHg, unit of measurement) (a normal blood pressure [BP] range 90/60 millimeter of mercury [mmHg] to 120/ 80 mmHg). Patient 1 had a respiratory rate of 20 breaths per minute (normal respiratory rate for adult at rest ranges from twelve [12] to eighteen [18] breaths per minute) and pulse rate at 57 beats per minutes [bpm] (normal pulse rate for an adult at rest ranges from sixty [60] to one hundred [100] bpm. COA stated the next V/S taken for Patient 1 was at 11:56 PM (on 12/14/2020). The COA stated Patient 1's V/S were checked eleven hours and forty-two minutes after the initial V/S were taken.

On 10/6/2023, at 11:04 AM, during concurrent interview with the Director of Emergency Department (DED) and record review of Patient 1's Flow sheet date range 12/13/2020 11:27 AM to 10/5/2023 11:27 AM, DED acknowledged Patient 1 had blood pressure (BP) measured on 12/15/2020 at 8:57 AM as 221/108 mmHg and again at 14:41 (2:41 PM) as 203/89 mmHg with no indication of any physician notification, clinical interventions, or re-evaluation of symptoms by a licensed nurse. On 10/5/2023, at 9:16 AM, during concurrent interview with the Clinical Operations Administrator (COA) and record review of Patient 1's Patient Summary Report, Undated, the COA stated Patient 1's electrocardiogram ([EKG] a test that measures electrical activity of the heart EKG) and blood chemistry studies were ordered after medical screening exam ([MSE] - an exam performed by a qualified professional to determine if a person has an emergency medical condition) on 12/14/2023 at 12:20 (12:20 PM) and Patient 1 was returned to the ED waiting room. COA stated Patient 1 was never re-assessed and eloped from the ED on 12/16/2020 at 6:40 PM.

A review of the facility's policy and procedure, titled, "2016 Provision of Care, Emergency Departments," dated 11/17/2025, indicated roles of a charge registered nurse (RN) was responsible for the unit activities, oversees patient care, and staff management for the assigned shift. Clinical RNs (nurse provide direct care) provide clinical care for patient for his/her assignment.

Based on interview and record review the facility failed to ensure licensed nurses assessed a patient every four hours according to facility's policies and procedures regarding patient care in the emergency department for one (1) of thirty sampled patients (Patient 1).

This deficient practice resulted to Patient 1 not being assessed and vital signs not being checked every four (4) hours.

Findings:

During an interview with the Clinical Operations Administrator (COA) and record review of Patient 1's medical records, on 10/5/2023, at 9:16 a.m., the COA stated Patient 1'sPatient Summary Reports showed while in waiting room, Patient 1's vital signs were checked:
1. On 12/14/2020 at 12:14 (12:14 p.m.) and 23:56 (11:56 p.m.).
2. On 12/15/2020 at 8:57 (8:57 a.m.), 14:15 (2:15 p.m.), 14:41 (2:41 p.m.), and 17:24 (5:24 p.m.)
3. On 12/16/2023 at 8:12 (8:12 a.m.) at discharge.

During an interview with the Clinical Operations Administrator (COA) and record review of Patient 1's medical records, on 10/5/2023, at 9:16 a.m., COA stated the licensed staff failed to provide appropriate reassessment to Patient 1, after being triaged as ESI level 3 ([ESI] is a five-level emergency department (ED) triage algorithm classifying patients into five groups from 1 [most urgent] to 5 [least urgent] based on patient ' s presenting health care problems and the number of resources their care might require). The COA stated according to hospital policy and procedure, after placing Patient 1 in the waiting room of the ED, Patient 1 required to be assessed every 4 hours.

During an interview with the Director of the Emergency Department (DED) on 10/6/2023, at 11:43 a.m., the DED stated that the Charge Nurse has oversight on all patient in the waiting room. It is the Charge Nurse responsibility to review all cases and identify need to expedite care. Patient 1 was noted to have waited in the waiting room for 2 days before leaving AMA.

A review of the facility's policy and procedure titled Triage & Medical Screening Guidelines for the ED, dated 10/2020, indicated triage will be performed by an emergency department registered nurse on all patients presenting to the Emergency Reception area. ESI level 3 are defined as conditions which generally need evaluation and treatment, but time was not a critical factor. ESI level 3 patients will be evaluated, and vital signs were to be repeated every 4 hours in the awaiting area.

A review of the facility's policy and procedure titled 2016 Provision of Care, Emergency Department, dated 11/17/2015, indicated roles of a charge registered nurse (RN) as responsible for the unit activities, oversees patient care and staff management for the assigned shift. Clinical RNs provide clinical care for patient for his/her assignment.

Based on interview and record review, the facility failed to ensure that the Condition of Participation of Emergency Services was met as evidenced by:

1. The facility failed to ensure an organized patient care process in the Emergency Department (ED)for one (1) of thirty sampled patients (Patient 1) in accordance with the facility's policy and procedure as evidence by the ED Provider (Physician Assistant 1, [PA 1]) did not complete a medical screening exam ([MSE] - an exam performed by a qualified professional to determine if a person has an emergency medical condition). (Refer to A - 1102).

2. The facility failed to ensure an organized patient care process in the Emergency Department (ED)for one (1) of thirty sampled patients (Patient 1) in accordance with the facility's policy and procedure as evidence by charge nurse not ensuring oversight of Patient 1's care in the ED. (Refer to A - 1102).

3. The facility failed to ensure a patient's medical screening exam ([MSE] - an exam performed by a qualified professional to determine if a person has an emergency medical condition) was completed for one (1) of thirty sampled patients (Patient 1) in accordance with the facility's policy and procedure on Emergency Department (ED) Triage and Medical Screening Guidelines. (Refer to A - 1104).

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

Based on interview and record review the facility failed to ensure an organized patient care process in the Emergency Department (ED)for one (1) of thirty sampled patients (Patient 1) in accordance with the facility's policy and procedure as evidence by:

1. Charge Nurse not ensuring oversight of Patient 1's care in the ED.

2. The ED Provider (Physician Assistant 1, [PA 1]) did not complete a medical screening exam ([MSE] - an exam performed by a qualified professional to determine if a person has an emergency medical condition).

The deficient practice resulted in Patient 1 waiting in the ED waiting room from 12/14/2022 at 12:30 p.m. to 12/16/2020 at 8:30 a.m. without being revaluated by medical physician and or the PA 1 and Patient 1 left against medical advice (AMA) on 12/16/2020 at 8:30 a.m.

Findings:

A review of Patient 1's Patient Summary Report, undated, indicated Patient 1 was admitted to facility emergency department for not feeling well, on 12/14/2020 at 11:12 a.m.

A review of the Patient Summary Report under Event Information, admission date 12/14/2020 at 11:12 a.m., indicated, Patient 1 was triaged as emergency severity index 3 ([ESI] - a five-level emergency department (ED) triage algorithm classifying patients into five groups from 1 [most urgent] to 5 [least urgent] based on patient ' s presenting health care problems and the number of resources their care might require).

During an interview with the Clinical Operations Administrator (COA) and record review of Patient 1's medical records (all record including Patient Summary Report with PA 1 orders), on 10/4/2023, at 12:30 p.m., the COA stated Patient 1 was seen by a provider (PA 1), on 12/14/2020 at 12:21 p.m., but that provider failed to document of a medical screening exam ([MSE] - an exam performed by a qualified professional to determine if a person has an emergency medical condition) and patient plan of care. Per COA, it (documentation) was important that a provider documents their ED notes, which includes a patient's MSE, because an ED Provider's notes describe the patient's medical plan of care. It ensures the administration of appropriate definitive care to a patient in a timely manner. There was no noted follow through of care from the medical provider or Charge Nurse, who has oversight of patient 1 care.

During an interview with the Clinical Operations Administrator (COA) and record review of patient 1's medical record, on 10/5/2023, at 9:40 a.m., the COA stated Patient 1 was triage and seen by a provider on 12/14/2020 at 12:21 p.m., Patient 1 was then directed to the waiting room where he waited for a follow up from the provider. Patient waited for 2 days. Patient opted to leave Against Medical Advice ([AMA], a patient choosing to leave the hospital before the treating physician recommends discharge), on 12/16/2020 at around 8:30 a.m., Patient was wheeled out to a bus stop by the facility staff (not identified). It was later found out that a bystander found the patient down and a bystander called 911.

During an interview with the Director of the Emergency Department (DED) on 10/6/2023, at 11:43 a.m., the DED stated that the Charge Nurse has oversight on all patient in the waiting room. It is the Charge Nurse responsibility to review all cases and identify need to expedite. Patient 1 was noted to have waited in the waiting room for 2 days before leaving AMA.

A review of the facility's policy and procedure (P&P), titled "Triage and Medical Screening Guidelines for the ED, " dated 10/2020, indicated that the Charge Nurse is responsible for the unit activities, oversees patient care and staff management for the assigned shift.

A review of the facility's policy and procedure (P&P), titled, "Triage and Medical Screening Guidelines for the ED," dated 10/2020, indicated that the ED was to provide a system to triage and perform initial medical screening exams to determine patients who require immediate attention, i.e. those with an emergency medical condition from those who may have their treatment delayed for a short period of time. A Medical screening will be performed by the Emergency Department Physician or Nurse/Practitioner/Physician Assistant in Emergency Services to ascertain the existence or not of an Emergency Medical Condition. Screening will be provided regardless of diagnosis, financial status, insurance status, race, color, national origin, handicapped or similar factors.

Based on interview and record review the facility failed to ensure a patient's medical screening exam ([MSE] - an exam performed by a qualified professional to determine if a person has an emergency medical condition) was completed for one (1) of thirty sampled patients (Patient 1) in accordance with the facility's policy and procedure on Emergency Department (ED) Triage and Medical Screening Guidelines.

This deficient practice resulted in Patient 1 with no documented MSE by the ED Provider (Physician Assistant 1 [PA 1]) , who examine Patient , on 12/14/2020 at 12:21 p.m.

Findings:

A review of Patient 1's Patient Summary Report, undated, indicated Patient 1 was admitted to facility emergency department for not feeling well, on 12/14/2020 at 11:12 a.m.

A review of the Patient Summary Report, under Tracking information, on 12/14/2020 at 11:12 a.m., indicated, Patient 1 was triaged as emergency severity index 3 ([ESI] - a five-level emergency department (ED) triage algorithm classifying patients into five groups from 1 [most urgent] to 5 [least urgent] based on patient's presenting health care problems and the number of resources their care might require).

A review of the Patient Summary Report, under order information, indicated PA 1 had given order for electrocardiogram ([EKG] a test that measures electrical activity of the heart), blood chemistry studies (blood test to check of abnormal level), and X-ray (imaging studies) of the chest at 12/14/2020 at 12:20 p.m.

During an interview with the Clinical Operations Administrator (COA) and record review of Patient 1's medical records, on 10/4/2023, at 12:30 p.m., the COA stated Patient 1 was seen by a provider on 12/14/2020 at 12:21 p.m., but that provider failed to document of a medical screening exam ([MSE] - an exam performed by a qualified professional to determine if a person has an emergency medical condition) and patient plan of care. Per COA, it (MSE) was important, , because the MSE was an ED Provider's notes that describe the patient's medical plan of care. It (MSE) ensures the administration of appropriate definitive care to a patient in a timely manner.

During an interview with the Clinical Operations Administrator (COA) and record review of Patient 1's medical record, on 10/5/2023, at 9:40 a.m., the COA stated Patient 1 was triage and seen by a provider on 12/14/2020 at 12:21 p.m. The COA verified that Patient 1's EKG and blood chemistry studies were ordered by PA 1, on 12/14/2020 at 12:20 p.m. The COA stated Patient 1 was then directed to the waiting room where he waited for a follow up from the provider. Patient waited for 2 days. Patient opted to leave Against Medical Advice ([AMA] - Patient choosing to leave the hospital before the treating physician recommends discharge) on 12/16/2020 at around 8:30 a.m.

A review of the facility's policy and procedure (P&P), titled, "Triage and Medical Screening Guidelines for the ED," dated 10/2020, indicated that the ED was to provide a system to triage and perform initial medical screening exams to determine patients who require immediate attention, i.e. those with an emergency medical condition from those who may have their treatment delayed for a short period of time. A Medical screening will be performed by the Emergency Department Physician or Nurse/Practitioner/Physician Assistant in Emergency Services to ascertain the existence or not of an Emergency Medical Condition. Screening will be provided regardless of diagnosis, financial status, insurance status, race, color, national origin, handicapped or similar factors.