HospitalInspections.org

Based on record review and interview the hospital failed to:

A. Ensure stroke policies and procedures were reviewed and revised to reflect current evidence based practice and standard of practice. This failed practice resulted in potential harm secondary to clinical deterioration in three (Patient #1,6 and 10) of 3 patients medical records reviewed and to all stroke patients presenting to the ED.

B. Ensure care provided to stroke patients in the emergency department was based on acceptable current evidenced based practice and national standards of practice. This failed practice resulted in potential harm secondary to clinical deterioration in three (Patient# 1, 6 and 10) of 3 patients medical records reviewed.

Findings:

A. Stroke Policies and Procedures

Review of policy titled "CVA (cerebrovascular accident) or Stroke" showed staff should document neurological deficit of facial palsy and arm weakness including the affected side and/or speech impairment. Patients determined not a candidate for t-PA (tissue plasminogen activator also known as the "clot buster") therapy should have continuous monitoring of vital signs and neurological status. The policy received Medical Staff approval on 07/21/17 and Governing Body on 07/31/17 with no revisions. The policy failed to recognize current evidence based guidelines and standards of practice for stroke as follows:

1. Expanding the documentation of a neurological deficit beyond facial weakness, arm weakness and speech impairment.
2. Administration of supplemental oxygen only to those patients who have an oxygen saturation below 94%
3. Management of blood pressure based on the type of stroke, patient presentation and eligibility for administration of tPA.
4. Current eligibility and contraindication criteria for tPA, including the relative contraindications and contraindications for patients who arrived between three and a half to four hours from last known normal.
5. Identification of assessments, interventions and management specific to spontaneous intracerebral hemorrhage.

Review of policy titled "Standards of Care" showed nursing interventions are based on established standards of practice and include protocols, guidelines and procedures for practice. Patient should receive care and treatment that meets the "standard of practice for the community".

A review of the American Stroke Association Guidelines titled "Early Management of Ischemic Stroke" dated 3/2013 stated supplemental oxygen is recommended when oxygen saturations levels are less than 94% using the least invasive method possible to achieve normoxia (normal level of oxygenation) ...elevated blood pressure in patients who do not receive t-PA it is recommended to lower BP by 15% within the first 24 hours following a stroke and consensus is medications should be held unless BP is greater than 220 mmHg systolic and/or 120 mmHg diastolic.

Review of the American Heart Association/American Stroke Association Guidelines titled "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage" dated 2010 showed patients with intracranial hemorrhage should have frequent vital sign and neurological assessments. And there should be reduction in BP when systolic BP is greater than 180mmHg using intermittent or continuous intravenous medications and assessment of patient every 15 minutes. Monitoring of blood glucose is recommended with maintenance of normoglycemia.

A review of the American Heart Association Guidelines titled "Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient Scientific Statement" showed signs of stroke can include but are not limited to visual difficulties (gaze preferences, visual field deficits, visual loss, diplopia, dysconjugate gaze), hemiparesis (weakness), paralysis, dysarthria, dysphagia, sensory (numbness) loss, nausea/vomiting, trunk/gait ataxia, limb ataxia, and severe headache.

Patient #1 arrived in the ED with a chief complaint of a sudden onset of hand and facial numbness approximately 45 minutes prior to arrival in the ED. Patient was triage 20 minutes after arrival as a Level 2(emergent). Nursing assessment performed and noted no facial weakness, clear speech, partial vision loss to right eye and bilateral hand numbness. Licensed independent provider performed medical screening exam approximately 30 minutes after patient arrival and noted sudden onset of partial visual loss, numbness in hand and generalized weakness reported by patient. On exam provider found right eye visual loss, bilateral hand numbness resolved upon arrival NIHSS score 1 for partial hemianopia. Aspirin 234 mg by mouth given. CT scan of head showed no acute findings. ED provider's clinical impression was noted as stroke and patient was transferred approximately two hours after arrival to another acute care facility for evaluation and treatment by neurological services. There was no evidence of ongoing neurological assessment or evaluation of the patient's ability to swallow prior to administering oral medication prior to transfer.

Patient #6 arrived in the ED at 10:08 am with a chief complaint of left sided weakness. Patient was immediately triaged, assigned as a Level 2 (emergent) and brought back into an ED room. Nursing assessment was performed and patient was noted to be drowsy, responds to manual stimuli, sedated, unable to follow directions, unable to move left arm, speech clear and understandable. Initial blood pressure was taken on admission at 10:08 am and was 189 mmHg systolic/106 mmHg diastolic. MSE performed by licensed independent provider and revealed patient to be lethargic, speech slurred, pupils unable to move left of midline, no movement of left side and inattention of left side. Computed tomography (CT) scan of the head was performed and results were received at 10:36 am which showed an acute right hemorrhagic infarction (intracerebral hemorrhage) with midline shift. Vital signs were not taken and IV BP medication were not provided to bring BP under control per current ICH guidelines. Vitals were taken at 11:02 am, BP was 198 mmHg/94mmHg. Order for Labetalol 5mg IV not ordered until 11:13 am and given at 11:20 am. Patient was given a second dose of Labetalol 5mg IV at 11:44 am, prior to re-assessment of patient's vital signs. Reassessment of vital signs were done at 11:47 am, BP 176 mmHg systolic/103 mmHg diastolic. Vital signs were not assessed every 15 minutes as recommended per current national guidelines and standard of practice for patients with spontaneous hemorrhage.

Patient #10 arrived in the ED with a chief complaint of slurred speech. Patient was triaged and assigned as a Level 2 (emergent) and brought back into an ED room. There was no evidence in the medical record the registered nurse performed a nursing assessment on the patient and there was no documentation in the patient's medical record. The licensed independent provider performed a medical screening exam 14 minutes after the patient's arrival and noted the patient reported dizziness, nausea upon standing and later had trouble speaking and weakness. On exam the provider noted difficulty speaking, slurred speech, mild weakness on the right lower extremity and oriented times three (person, place and time). CT scan of the head showed a "hypodensity in the left pons compatible with ischemic changes". Provider's impression was noted as "rule out CVA". Approximately two hours and 30 minutes after arrival the patient was transferred to another acute care facility for a higher level of care including a neurology consultation. During this time prior to transfer there was no evidence of monitoring by nursing of the patient's neurological status.


B. Stroke Care and Treatment

Review of policy titled "CVA (cerebrovascular accident) or Stroke" showed staff should document neurological deficit of facial palsy and arm weakness including the affected side and/or speech impairment. Patients determined not a candidate for t-PA (tissue plasminogen activator also known as the "clot buster") therapy should have continuous monitoring of vital signs and neurological status. There was no evidence for interventions on the management of intracerebral hemorrhage until the patient could be transferred to ensure optimal patient health outcomes and safety.

Review of policy titled "Emergency Rules and Regulations: Emergency Section of Hospital Bylaws" showed the RN in the ED is responsible for the performance of an initial assessment and collection of data for presentation to the physician or licensed independent practitioner.

Review of policy titled "Assessment and Evaluation" showed all patients presenting to the ED should be assessed by the RN on duty and assessment documented.

Review of policy titled "Standard of Care" showed the ED RN should perform a comprehensive nursing assessment within 15 minutes of patient admission.

A review of the American Heart Association/American Stroke Association Guidelines titled "Early Management of Ischemic Stroke" dated 3/2013 stated neurological assessments using a standardized tool should be performed frequently for patients with suspected stroke.

A review of the American Heart Association/American Stroke Association Guidelines titled "Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient Scientific Statement" showed neurological assessments should be done frequently for patients with suspected stroke ...stroke patients are kept NPO (nothing by mouth) including any medications until assessment of the patient's ability to swallow can be assessed.

Review of the American Heart Association/American Stroke Association Guidelines titled "Guidelines for the Management of Spontaneous Intracerebral Hemorrhage" dated 2010 showed patients with intracranial hemorrhage should have frequent vital sign and neurological assessments. And there should be reduction in BP when systolic BP is greater than 180mmHg using intermittent or continuous intravenous medications and assessment of patient every 15 minutes. Monitoring of blood glucose is recommended with maintenance of normoglycemia.

Patient #1 arrived in the ED with a chief complaint of a sudden onset of hand and facial numbness approximately 45 minutes prior to arrival in the ED. Patient was triage 20 minutes after arrival as a Level 2(emergent). Nursing assessment performed and noted no facial weakness, clear speech, partial vision loss to right eye and bilateral hand numbness. Licensed independent provider performed medical screening exam approximately 30 minutes after patient arrival and noted sudden onset of partial visual loss, numbness in hand and generalized weakness reported by patient. On exam provider found right eye visual loss, bilateral hand numbness resolved upon arrival NIHSS score 1 for partial hemianopia. Aspirin 234 mg by mouth given. CT scan of head showed no acute findings. ED provider's clinical impression was noted as stroke and patient was transferred approximately two hours after arrival to another acute care facility for evaluation and treatment by neurological services. There was no evidence of ongoing neurological assessment or evaluation of the patient's ability to swallow prior to administering oral medication prior to transfer.

Patient #6 arrived in the ED at 10:08 am with a chief complaint of left sided weakness. Patient was immediately triaged, assigned as a Level 2 (emergent) and brought back into an ED room. Nursing assessment was performed and patient was noted to be drowsy, responds to manual stimuli, sedated, unable to follow directions, unable to move left arm, speech clear and understandable. Initial blood pressure was taken on admission at 10:08 am and was 189 mmHg systolic/106 mmHg diastolic. MSE performed by licensed independent provider and revealed patient to be lethargic, speech slurred, pupils unable to move left of midline, no movement of left side and inattention of left side. Computed tomography (CT) scan of the head was performed and results were received at 10:36 am which showed an acute right hemorrhagic infarction (intracerebral hemorrhage) with midline shift. Vital signs were not taken and IV BP medication were not provided to bring BP under control per current ICH guidelines. Vitals were taken at 11:02 am, BP was 198 mmHg/94mmHg. Order for Labetalol 5mg IV not ordered until 11:13 am and given at 11:20 am. Patient was given a second dose of Labetalol 5mg IV at 11:44 am, prior to re-assessment of patient's vital signs. Reassessment of vital signs were done at 11:47 am, BP 176 mmHg systolic/103 mmHg diastolic. Vital signs were not assessed every 15 minutes as recommended per current national guidelines and standard of practice for patients with spontaneous hemorrhage.

Patient #10 arrived in the ED with a chief complaint of slurred speech. Patient was triaged and assigned as a Level 2 (emergent) and brought back into an ED room. There was no evidence in the medical record the registered nurse performed a nursing assessment on the patient and there was no documentation in the patient's medical record. The licensed independent provider performed a medical screening exam 14 minutes after the patient's arrival and noted the patient reported dizziness, nausea upon standing and later had trouble speaking and weakness. On exam the provider noted difficulty speaking, slurred speech, mild weakness on the right lower extremity and oriented times three (person, place and time). CT scan of the head showed a "hypodensity in the left pons compatible with ischemic changes". Provider's impression was noted as "rule out CVA". Approximately two hours and 30 minutes after arrival the patient

Based on record review, interview, and observation, the hospital failed to ensure the safety and well being of patients by:

a. establishing clear restraint policies in 2 of 2 polices in accordance with national standards of practice regarding correct restraint application, monitoring, and documentation This failed practice had the potential to increase the safety risk to any patient requiring restraints by staff's lack of knowledge of the hospital requirements for chemical restraints, age specific care, use of posey vests, and assessment and documentation guidelines for other types of restraints.

b. ensuring staff competencies regarding correct restraint application, monitoring, assessment, and documentation for 8 (Staff #I, N, M, S, T, U, V, and W) of 8 nurses. This failed practice had the potential to increase the risk of injury to any patient requiring restraints from inappropriate restraint application or inadequate monitoring.

c. implementing a security program for the hospital and campus to minimize the risk to staff, patients, and visitors. This failed practice resulted in at least 4 identified security / safety events in 2017, and potentially reoccurrence of event due to lack of debriefing of the events and communicating the events to the Governing Body.

d. providing adequate patient care and monitoring, including search for contraband and 1:1 monitoring for 8 psychiatric patients (Patient # 2, 3, 5, 8, 9, 11, 13, & 14) of a total sample of 20 patients presented to the ED with suicidal and/ or homicidal ideation and /or psychosis. This failed practice resulted in the increased safety risk for staff and Patient #9, who upon discharge was in possession of a knife found by police and the potential risk to staff and the 200 emergency patient (average) receiving services at the hospital each month.

Findings:

a. Restraint Policies
A review of the restraint log from 2016-09/2017 showed no names of patients documented on the log; however, had restraints such as wrist, posey, and medications available to the in-patient and emergency departments.

On 09/11/17 at 11:30 am, Staff B and Staff J stated the hospital had no restraints used in over 2 years.

The hospital provided 2 restraint policies.
1. A review of the policies titled, "Patient restraints (dated 11/12)" failed to differentiate between the requirements of restraints in violent and non-violent situations. The policy did not address assessment and documentation requirements. The policy documented steps when applying a posey vest restraint and did not address assessment and documentation requirements. The policy documented chemical restraints included the following drugs: thorazine, haldol, mellaril, and valium and ativan (when used for agitation); no other guidelines are given. The policy documented when a patient exhibited excessive sedation such as lowered respirations and was not able to arouse, the patient should be monitored as directed or at least with continuous pulse oximetry, telemetry, and have only hourly visual assessments. The policy failed to address age specific requirements.

2. A review of the policy titled, "Combative Restraints (dated 07/31/17)" failed to differentiate between the requirements of restraints in violent and non-violent situations. The policy documented the patient should be checked "frequently" (at least every hour). The policy documented Emergency Department (ED) room physician or RN would select the type of restraint that was appropriate to the patient's condition while in the ED. The policy did not provide any restraint selection guidelines for the RN, or describe appropriate types of restraints for designated patient conditions. The policy documented in emergency physical restraint, the physician's order needed to be obtain within 2 hours of application of restraint.

(In an American Psychiatric Nurse Association paper titled, "Position on the Use of Seclusion & Restraint 04/17" documented, " Standard: Seclusion or restraint is initiated by qualified staff authorized by the organization to initiate seclusion or restraint in a behavioral emergency and must be followed by an order from a physician or Licensed Independent Practitioner (LIP). Intent: The initiation of seclusion or restraint should...involve notification of a physician or LIP for a written, verbal or telephone order to include the reason for the seclusion or restraint, the specific type of restraint to be utilized, the duration of the order and the behavioral criteria for release.")
The policy did not specify what assessment, monitoring, and documentation were required for the patient receiving chemical restraint. The policy documented chemical restraints included the following drugs: thorazine, haldol and mellaril (newly RX [prescribed]), and valium and ativan (when used for agitation); no other guidelines are given. The policy failed to address age specific requirements.

On 09/12/17 at 12:30 pm, Staff B stated the hospital no longer used posey vest and leather restraints, and did not use chemical restraint. Staff B stated restraint training was being implemented during the course of the survey.

b. Restraint Competency
A review of the documents titled, "RN Basic Competency Verification Form" and "Initial ED / Critical Care RN Competency Verification Form" showed no competency evaluation for restraints or alternative measures to restaints.

A review of 8 registered nurse / licensed practical nurse personnel files showed: 8 (Staff #I, N, M, S, T, U, V, and W) of 8 nurses did not contain evidence of use of restraint competency or alternative measures to restaints.

On 09/12/17 at 12:30 pm, surveyor observed Staff B provide inservice training on restraints utilizing "Restraint Competency for RNs and LPNs". The competency check sheet did not include posey vest or leather restraint, but were contained within the hospital's restraint policies.

On 09/12/17 at 12:30 pm, Staff B stated the hospital no longer used posey vest and leather restraints, and did not use chemical restraint.

c. Security Program

1. Security Plan and Presence of Security Staff

A review of a hospital policy titled, "Security Program (dated 03/08) documented " Maintenance personnel, in addition to others designated by Hosp. Admin. may act as security personnel to enforce hospital policies in limited situations....Any threat to security will be reported to Police". The policy failed to address which staff would be designated by hospital administration to act as security personnel and what policies were to be enforced. The policy did not address what security training would be required.

On 9/07/17 & 09/08/17, staff were interviewed regarding the security of the hospital and campus. All staff interviewed (Staff # A, P, I, and N) stated the hospital and campus had no employed security staff.

09/07/17 at 1:25 pm, Staff P stated due to his large size, the staff sometimes called Staff F, the Case Manager for security matters.

09/08/17 10:15 am, Staff A stated the hospital locked doors at night as part of their security program.

2. Incidents and Reporting
A review of incidents reports from 2016 through 9/17 showed no documentation of security situations that involved police notification.

During the course of the survey, 4 events were identified through medical record review and interview as security issues, and none of which were reported through the hospital's QAPI system.

a. A review of medical record for Patient #14 showed on 08/18/17 at 2-3:00 am, an ED patient was handcuffed and escorted off hospital premises.

b. On 09/06/17 of 10:29 am, Staff W stated Patient # 22 was picked up from the ED to transport to a psychiatric facility for further treatment for suicidal ideation. Staff W stated after leaving the ED, when the patient was searched, the patient had a knife.

c. On 09/07/17 at 1:50 pm, Staff I stated when unruly, angry, drunk patients come to the ED, she tried to maintain a calm voice and try not to surprise them. She stated one time a patient hit her. She said if a patient is drunk and requests pain medication, she would provide patient education and tell the patient he could not have pain medication. Staff I provided no specific dates of occurrences.

d.. 09/08/17 at 10:15 am, Staff A stated the last event in which the police were called involved a patient, whose daughter had power of attorney, and a son that was presented with a tribal restraining order. The son was angry, and the hospital, fearing retaliation, was placed on "lockdown". Staff A stated the hospital had no policy regarding disruptive family or lockdown situations.

09/08/17 at 11:06 am, Staff B stated in May 2017, the hospital was on lockdown and police were called due to a fear of retaliation from a patient's son. She stated the son had called and threatened the hospital staff. Staff B stated no incident report was completed and she did not know if the Governing Body knew of the situation. Staff B stated the hospital did not complete an incident report when police were requested, and the police maintain records of the situations. She stated she completes incident report for such situations, but not all staff document the situation on a report.

09/08/17 at 10:15am, Staff A, CEO stated incident reports should be completed for any disruptions requiring police intervention, but felt that the staff probably were not completing the form. Staff A stated incidents involving the police were not debriefed or reported to QAPI, and did not know the number of times in the past year the police had been used for hospital security matters.

09/05/17 at 1:48 pm, Staff J stated if a psychiatric patient was disruptive, and the police were called, the situation would not warrant incident reporting.

3. Indications to Notify Police
09/07/17 at 1:35 pm, Staff A stated if a patient was belligerent, the staff's main action was to call the police. She stated the staff usually call the police for disruptive schizophrenics and alcoholic patients. She stated the police would try to calm the patient, or will "throw them in jail".

09/08/17 10:15 am, Staff A stated the staff called the local police department for disruptions.

09/05/17 at 1:48 pm, Staff J stated if a psychiatric patient was disruptive, the police were called.

09/08/17 at 11:06 am, Staff B stated when she was oriented as a new hospital employee, she was told to contact the police for assistance as needed, and report situations to administration. She stated the hospital did not employ security staff.

09/07/17 at 2:27 pm, Staff O stated the staff had called the police three to four times for situations like intoxicated patients, who started getting aggressive in any way towards the staff. She said upon arival, the police tell a patient not to return if the patient had come to the hospital repeatedly.

09/07/17 at 1:50 pm, Staff I stated staff would call the police for disruptive or dangerous patients. Staff I stated police officers would come to the hospital and stay with the patient, and the nurse was responsible for monitoring the patient.

09/07/17 at 4:00 pm, Staff N stated if the staff have situations in which the staff do not feel safe, they will call the police. She stated the physician participates in the decision to call the police.

4.. Care of the Psychiatric Patient

A review of document titled, "Emergency Room Register from 01/17 to 08/17, showed eight (Patient # 2, 3, 5, 8, 9, 11, 13, & 14) of 8 psychiatric patients of a total sample of 20 patients presented to the ED with suicidal and/ or homicidal ideation and /or psychosis, and a review their medical records showed no evidence patients were searched and protected from contraband, and provided 1:1 supervision.
Patient # 2 presented to ED with complaints of self harm and had punched a wall with left hand, under emergency order of detention, and was discharged to a mental health facility by police escort.
Patient # 3 presented to ED with complaint of acute psychosis and taking excessive narcotic, and was discharged to a mental health facility.
Patient # 5 presented to ED with complaint of psychosis, paranoia, and thought he was superhuman, and was discharged to a mental health facility.
Patient # 8 presented to ED via police with complaint psychosis and attempted to burn house down, under emergency order of detention,and was discharged to a mental health facility.
Patient # 9 presented to ED with complaint of suicidal/ homicidal ideation and scratched self with knife, under emergency order of detention,and was discharged to a mental health facility. The patient was in possession of a knife during ED visit.
Patient # 11 presented to ED with complaint of intentional overdose of medication according to police. Patient was released to mother after denying suicidal ideation at discharge, and was to be admitted the following day to a mental health facility.
Patient # 13 presented to ED with complaints of taking "bad drugs" and stated wanted to jump of a bridge, under emergency order of detention,and was discharged to a mental health facility.
Patient # 14 presented to ED with complaint of seven wrist lacerations and self harm, under emergency order of detention,and was discharged to a mental health facility.

A review of a document titled "Clinical Specialty Areas - Issues to Assess and/or Monitor" showed risk management should periodically evaluate risks associated with high-risk clinical specialties and monitor for changes. Common high-risk clinical areas include behavioral health. Clinical data for behavioral health included de-escalation and emergency response to a behavioral health emergency, facility safety, suicide assessment and prevention, patient monitoring, patient death/injury or near miss, staff injury or near miss, and security and disruptive patient handling events and near misses.

A review of a policy titled "Standard of Care" showed nursing care would be provided in a safe and therapeutic environment. The policy documented measures should be initiated to correct any unsafe environmental conditions seen, patients should be evaluated for potential harmful items, and provisions should be made for adequate staff supervision to ensure the safety of the patient.

On 09/11/17 at 10:29 am, surveyors requested policies and procedures for the emergency care and treatment of patients with psychiatric needs. None were provided.

On 09/06/17 of 10:29 am, Officer W stated Patient # 9 was picked up from the ED to transport to a psychiatric facility for further treatment for suicidal ideation. Officer W stated after leaving the ED, when the patient was searched, the patient had a knife.

On 09/07/17 at 4:00 pm, Staff N, RN, stated care for psychiatric patients had not been defined at the hospital. Staff N stated at other hospitals in she had worked, suicidal / homicidal psychiatric patients were dressed in gowns and were searched for contraband and received 1:1 monitoring and documentation training.

Based on record review and interview the governing body failed to monitor and implement policies and procedures that are reflective of current practice and provided within a safe environment for patients. This failed practice had the potential to affect the clinical care provided and patient safety for two (Patient #1 and 10) of three patients.

Findings:

Review of hospital document titled "QCC Meeting Minutes" dated 07/11/17 showed the quality committee approved the ER Policy and Procedures Manual. The meeting minutes failed to reflect review of policies and procedures were based on current practice standards to ensure quality care and patient safety.

Review of hospital document titled "Executive Board of Director Meeting Minutes" dated 07/31/17 showed the executive board of directors approved the ER Policy & Procedures Manual. The meeting minutes failed to reflect review of the policies and procedures were based on current practice standards to ensure quality care and patient safety.

Review of hospital policy titled "Emergency Rules and Regulations: Emergency Section of Hospital Bylaws" showed the policy was reviewed on 07/31/17, received medical staff approval on 07/21/17 and was approved by the Governing Body on 07/31/17. The policy showed the RN would be responsible in the ED for the initial evaluation, data collection and exam and present the information to the physician, physician assistant (PA) or nurse practitioner (NP) who is on call. A designated physician would be responsible for providing instruction to the RN on completing an emergency evaluation and assessment and upon completion of this training the RN would be qualified to perform an ED evaluation and assessment. The physician, PA or NP would determine the patient's classification as emergent, urgent or non-urgent upon notification by the RN and designate the place of treatment. RN is responsible for effectively evaluating phone calls made to the hospital by patients for the need of the patient to present to the ED for further assessment and evaluation. On 09/07/17 at 1:50 pm, Staff I stated when the provider is scheduled he/she is on hospital property performs the evaluation or medical screening examination. Staff I reported the RN is responsible for the initial triage assessment and vital signs. On 09/07/17 at 3:10 pm, Staff Q stated he/she as a licensed medical provider would be responsible for performing the patient evaluation and determining patient classification in person not over the phone. Staff Q reported that he/she was not aware of this policy and does not reflect the practice in the ED.

Review of hospital policy titled "Assessment and Evaluation" from the Emergency Department Policies and Procedures showed the policy was reviewed on 07/31/17 received medical staff approval on 07/21/17 and was approved by Governing Body on 07/31/17. The policy stated every patient who presented to ED should be assessed by an RN, once the assessment was completed the RN would be responsible for calling the physician, PA or NP and providing the information gathered from their assessment to obtain instructions and the patient classification. Once information has been provided to the physician, PA or NP and classification has been determined not to be an emergency the physician or on-call medical person may opt to see the patient in clinic or assess the patient by telephone for treatment. On 09/07/17 at 1:50 pm, Staff I stated when the provider is scheduled he/she is on hospital property performs the evaluation or medical screening examination. Staff I reported the RN is responsible for the initial triage assessment and vital signs. On 09/07/17 at 3:10 pm, Staff Q stated he/she as a licensed medical provider would be responsible for performing the patient evaluation and determining patient classification in person not over the phone. Staff Q reported that he/she was not aware of this policy and does not reflect the practice in the ED.

Review of hospital policy titled "CVA or Stroke" showed the policy was reviewed on 07/31/17 received medical staff approval on 07/21/17 and was approved by Governing Body on 07/31/17. The review and approval of this policy failed to show the policy was updated to include revision of the exclusion criteria, addition of relative exclusion criteria and criteria for administering t-PA to patients who present in the expanded window from three to four and a half hours based on current practice standards.

A review of the American Stroke Association Guidelines titled "Early Management of Ischemic Stroke" dated 3/2013 showed t-PA exclusion criteria for stroke patients who presented within three hours of stroke onset included but are not limited: "significant" head trauma within three months", blood glucose less than 50mg/dL, arterial puncture at non-compressible site in the previous seven days, current use of direct thrombin inhibits or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count). Relative exclusion criteria (those who may receive despite one or more criteria after considering risk versus benefit) include but are not limited to: minor or rapidly improving stroke and major surgery or serious trauma within 14 days. And relative exclusion criteria for patients presenting to the ED within three to 4.5 hours includes: greater than 80 years old, NIHSS (National Institutes of Health Stroke Scale) greater than 25, oral anticoagulant therapy regardless of INR and history of both diabetes and prior ischemic stroke.

On 09/08/17 at 11:08 am, Staff B stated he/she knew the policies had been a big concern for the hospital and Staff R (Corporate Clinical Chief Officer) was going to come and make sure they were all came up to the current practice standards. Staff B stated only a few of the policies have been revised by the medical providers and the Governing Board.

On 09/12/17 at 11:20 am, Staff J stated he/she has not administered t-PA since last part of 2016. Staff J reported he/she was not responsible for reviewing and revising the ED policies and procedures. Staff J stated the medical staff usually reviewed the ED policies.

Based on record review and interview, the hospital failed to ensure sufficient staff were available to provide the nursing care on 2 shifts from staff schedules from 01/01/17 to 09/05/17 in which a RN was assigned to both the emergency and in-patient departments simultaneously.

This failed practice had the potential for patient care needs to go unmet due to urgent patient needs which required RN skills occurring in both departments simultaneously, which would increase the safety risk for the 20 in-patients and 200 emergency patient (average) receiving services at the hospital each month.

Findings:

A review of the hospital titled, "Staffing and Attire in ER (dated 07/31/17)" documented the staffing for 24 hours a day would consist of an RN, who may call in a second RN when "the occasion presents itself by need."

A review of staff schedules from 01/01/17 to 09/05/17 showed 2 shifts in which the only assigned registered nurse (RN) was responsible for patients in the in-patient and the emergency department (ED) simultaneously. The RN was not only responsible for direct patient care; but also for supervising other staff. The RN, when providing care to the ED patient, would be dependent on the in-patient LPN to assess and convey patient needs that were beyond the LPN's scope of practice.

(The "Oklahoma Nurse Practice Act (dated 11/16)" allows the LPN to contribute to the assessment of the health status of individuals and groups, and participate in the development and modification of the plan of care, under the supervision of a RN.)

*On 07/07/17, shift: 7 pm to 7 am, Staff J was assigned to both units, and the in-patient unit had 3 patients (Patients # 39,40,42) , and the ED had 10 (Patients #2, 32, 33, 35, 36, 37, 38, 39, 40, 41) patient visits.

*On 08/04/17, shift: 7 pm to 7 am, Staff J was assigned to both units, and the in-patient unit had 1 patients (Patients # 29), and the ED had 3 patient (Patients #39, 40, 42) visits.

On 09/07/17 at 4:00 pm, Staff N stated when 2 RN are not on the schedule, one RN must go back and forth from In-patient and ED. She stated she tries to get her responsibilities done for the in-patients, such as RN assessments. She stated at times there is not enough staff. She said if she was with a patient in the ED, the LPNs "were good to come tell me" of in-patient needs. She stated sometimes the staff are shorthanded and are just thrown in.

On 09/07/17 at 4:32 pm, Staff J stated when she is not on duty, an in-patient RN would float back and forth supervising and rendering care to both in-patients and ED patients.

Based on record review and interview, the hospital failed to ensure:
1. patients of special populations were assessed, monitored, and cared for in accordance with standard of practice, which had the potential to increase the risk of inappropriate care being provided and adverse patient outcomes for:

a. 6 infant/ pediatric inpatients (Patients # 18, 22, 25, 26, 27, & 28) admitted from 01/29/17 to 04/13/17,
b. 2 patients (Patient #1 and 10) of 3 patients with stroke symptoms of 140 patients presenting to the ED from
08/03/17 to 09/07/17, and
c. 8 (Patient # 2, 3, 5, 8, 9, 11, 13, & 14) of 8 psychiatric patients of a total sample of 20 patients presented to the ED with suicidal and/ or homicidal ideation and /or psychosis from 01/17 to 08/17.

2. nursing staff were competent to render care to special patient populations, which had the potential to increase the risk of inappropriate care being provided and adverse patient outcomes for:

a. 6 infant/ pediatric inpatients (Patients #18, 22, 25, 26, 27, & 28) admitted from 01/29/17 to 04/13/17,
b. 3 patients (Patient #1 and 10) of 3 patients with stroke symptoms of 140 patients presenting to the ED from 08/03/17 to 09/07/17, and

(Refer to Tag C-0294)

Based on record review and interview, the hospital failed to ensure:
1. patients of special populations were assessed, monitored, and cared for in accordance with standard of practice, which had the potential to increase the risk of inappropriate care being provided and adverse patient outcomes for:

a. 6 infant/ pediatric inpatients (Patients #18, 22, 25, 26, 27, & 28) admitted from 01/29/17 to 04/13/17,
b. 2 patients (Patient #1and 10) of 3 patients with stroke symptoms of 140 patients presenting to the ED from 08/03/17 to 09/07/17, and
c. 8 (Patient # 2, 3, 5, 8, 9, 11, 13, & 14) of 8 psychiatric patients of a total sample of 20 patients presented
to the ED with suicidal and/ or homicidal ideation and /or psychosis from 01/17 to 08/17.

2. nursing staff were competent to render care to special patient populations, which had the potential to increase the risk of inappropriate care being provided and adverse patient outcomes for:

a. 6 infant/ pediatric inpatients (Patients #18, 22, 25, 26, 27, & 28) admitted from 01/29/17 to 04/13/17,
b. 2 patients (Patient #1 and 10) of 3 patients with stroke symptoms of 140 patients presenting to the ED from 08/03/17 to 09/07/17, and

3. implement a policy for verifying OK Board of Nursing licensure to include disciplinary action or restrictions on licensure, and communicate the findings to the Governing Body. This failure occurred in 1 (Staff K) of 8 (Staff I, K, M, N, S, T, V, & U) nursing staff, and had the potential for the Governing Body to be uninformed regarding the employees for which the are responsible.

Findings:

1. Assessment, Monitoring, and Care
a. Infant / Pediatric Patients
A review of document titled, "Statistical Report 08/17" showed 38 [infant] & pediatric patients were admitted to the inpatient unit from 05/16 to 04/17.

A review of 6 medical records of infant/ pediatric patients showed deficient practices in nursing care of the infant / pediatric patient regarding IV infusions, weights, intake and outputs, neurology assessment, and fall assessments.

On 09/12/17 at 2:35 pm, Staff B, stated the hospital had no policies or competencies for the care of infant or pediatric patients.

Weights
A review of 6 medical records of infant/ pediatric patients of a total sample of 20 showed 6 (Patients #18, 22, 25, 26, 27, & 28) of 6 patients were weighed in pounds which had the potential to increase the likelihood of errors in medication dosages and IV fluid rates which should be calculated in kilograms.

(A review of U.S. Department of Health & Human Services - Agency for Healthcare Research and Quality in an article titled "A Weighty Mistake- dated March 2013" documented all providers that care for children should have access to infant and pediatric scales that weigh children in kilograms.)

On 09/12/17 at 2:35 pm, Staff B, stated the hospital had no policies (regarding measuring weights) of infant or pediatric patients.

Intake and Outputs (I&O)
A review of 6 medical records of infant/ pediatric patients of a total sample of 20 showed 5 (Patients #18, 25, 26, 27, & 28) of 6 patients had a physician's order for I & O which had the potential to impede the early detection of fluid and electrolyte imbalance.
*Patient #18, 2 years, had 1 entry for intake and no output documented during the 1 day hospitalization.
*Patient #25, 6 years, had 1entry of I & O during the 3 day hospitalization,
*Patient #26, 4 month old, had no I & O during the 2 day hospitalization,
*Patient #27, 2 years, intake was performed per shift but no output documented during the 2 day hospitalization, and
*Patient #28, 2 years, had 1 entry which indicated the input was 2100 milliliter and only 3 milliliter out of dark cloudy urine with no action taken during the 3 day hospitalization.
On 09/12/17 at 2:35 pm, Staff B, stated the hospital had no policies (regarding intake and output) of infant or pediatric patients.

IV (Intravenous) Infusions
A review of 6 medical records of infant/ pediatric patients of a total sample of 20 showed 4 (Patients #18, 25, 28, & 29) of 6 patients received IV infusion. Despite the use of an infusion pump, the lack of a volume control chamber with a limited capacity had the potential of accidental bolus of medication or fluid, and resulted in increased risk of serious adverse health outcomes of the 4 (Patients #18, 25, 28, & 29) of 6 infant/ pediatric patients receiving IV infusion.

The medication administration record for the 4 patients ranging from 2 - 7 years old showed the following IV bag volumes:

*Patient #18 had an IV , but volume was not documented.
*Patient #25 had 500 milliliter IV bag hanging,
*Patient #28 had 1000 milliliter IV bag hanging, and
*Patient #29 had 1000 milliliter IV bag hanging.

On 09/12/17 at 2:35 pm, Staff B, stated the hospital had no policies (regarding safe administration of IV fluids) for infant or pediatric patients. Staff B stated the hospital did not use buretrols or other volume control chamber systems for infant or pediatric patients.

Neurological Assessments and Care
A review of 6 medical records of infant/ pediatric patients of a total sample of 20 showed 4 (Patients #22, 26, 27, & 28) of 6 patients, as young as 4 months old, admitted with seizure disorder, were assessed using an adult Glasgow Coma Scale, an adult motor evaluation, and had no documentation of seizure precautions such as padded bedrails. This failed practice resulted in inadequate neurologically assessments in 4 (Patients #22, 26, 27, & 28) of 6 infant/ pediatric patients and failure to implement an inaccurate plans of care, and had the potential to increase the risk to the patients due lack of symptom recognition and precautions taken.

(The Pediatric Glasgow Coma Scale( PGCS) is the equivalent of the Glasgow Coma Scale (GCS) used to assess the mental state of infant/ pediatric patients. The two scales differ in how eye, verbal and motor responses are assessed based on age and are not interchangeable.)

On 09/12/17 at 2:35 pm, Staff B stated the hospital had no policies regarding neurological assessments of infant or pediatric patients.

Fall Assessments and Care
A review of 6 medical records of infant/ pediatric patients of a total sample of 20 showed 3 (Patients #18, 22, & 26) of 6 infant/ pediatric inpatients failed to have any fall risk assessment, and 3 (Patients #25, 27, & 28) of 6 infant/ pediatric inpatients had adult fall assessments which failed to accurately assess age specific differences. This failed practice resulted in inadequate fall risk assessments of six (Patients #18, 25, 22, 26, 27, & 28 ) of six infant/ pediatric inpatients and failure to implement an inaccurate plans of care, and had the potential to increase the risk to the patients due safety precautions taken.

*Patient #18, 2 years had no fall risk assessment performed during the 1 day hospitalization.
*Patient #22, 6 years, had no fall risk assessment performed during the 2 day hospitalization,
*Patient #25, 6 years, had an adult fall risk assessment performed each shift during the 3 day hospitalization,
*Patient #26, 4 month old, had no fall risk assessment during the 2 day hospitalization, but in an initial assessment documented to have a "steady gait",
*Patient #27, 2 years, had 1 adult fall risk assessment during the 2 day hospitalization, and
*Patient #28, 2 years, had an adult fall risk assessment performed each shift during the 3 day hospitalization.

On 09/12/17 at 2:35 pm, Staff B stated the hospital had no policies instructing staff regarding fall assessment of care of infant or pediatric patients.

b. Stoke Patients

Review of hospital policy titled "Assessment and Evaluation" showed these patient who presented to ED should be assessed by an RN.

Review of hospital policy titled "CVA or Stroke" showed patients should have continuous monitoring of vital signs and neurological status.

A review of the American Stroke Association Guidelines titled "Early Management of Ischemic Stroke" dated 3/2013 stated neurological assessments using a standardized tool should be performed frequently for patients with suspected stroke

A review of the American Heart Association Guidelines titled "Comprehensive Overview of Nursing and Interdisciplinary Care of the Acute Ischemic Stroke Patient Scientific Statement" showed neurological assessments should be done frequently for patients with suspected stroke ...stroke patients are kept NPO (nothing by mouth) including any medications until assessment of the patient's ability to swallow can be assessed.

Patient #1 arrived in the ED with a chief complaint of a sudden onset of hand and facial numbness approximately 45 minutes prior to arrival in the ED. Nursing assessment performed and noted no facial weakness, clear speech, partial vision loss to right eye and bilateral hand numbness. Aspirin 234 mg by mouth given. There was no evidence of monitoring by nursing of the patient's neurological status prior to transfer or performance of a swallow screen prior to administration of oral medication according to policy and/or standard of practice.

Patient #10 arrived in the ED with a chief complaint of slurred speech. There was no evidence in the medical record the registered nurse performed a nursing assessment. Approximately two hours and 30 minutes after arrival the patient was transferred to another acute care facility for a higher level of care including a neurology consultation. During this time prior to transfer there was no evidence of monitoring by nursing of the patient's neurological status according to policy and/or standard of practice.

c. Psychiatric Patients
A review of log titled, "Emergency Room Register from 01/17 to 08/17, showed 8 (Patient # 2, 3, 5, 8, 9, 11, 13, & 14) of 8 psychiatric patients of a total sample of 20 patients presented to the ED with suicidal and/ or homicidal ideation and /or psychosis, and a review their medical records showed no evidence patients were searched and protected from contraband, and provided 1:1 supervision.
Patient # 2 presented to ED with complaints of self harm and had punched a wall with left hand, under emergency order of detention, and was discharged to a mental health facility by police escorts
Patient # 3 presented to ED with complaint of acute psychosis and taking excessive narcotic, and was discharged to a mental health facilitys
Patient # 5 presented to ED with complaint of psychosis, paranoia, and thought he was superhuman, and was discharged to a mental health facility.
Patient # 8 presented to ED via police with complaint of psychosis and attempted to burn house down, under emergency order of detention,and was discharged to a mental health facility.
Patient # 9 presented to ED with complaint of suicidal/ homicidal ideation and scratched self with knife, under emergency order of detention,and was discharged to a mental health facility. The patient was in possession of a knife during ED visit.
Patient # 11 presented to ED with complaint of intentional overdose of medication according to police. Patient was released to mother after denying suicidal ideation at discharge, and was to be admitted the following day to a mental health facility.
Patient # 13 presented to ED with complaints of taking "bad drugs" and stated wanted to jump of a bridge, under emergency order of detention,and was discharged to a mental health facility.
Patient # 14 presented to ED with complaint of seven wrist lacerations and self harm, under emergency order of detention,and was discharged to a mental health facility.

A review of a document titled "Clinical Specialty Areas - Issues to Assess and/or Monitor" showed risk management should periodically evaluate risks associated with high-risk clinical specialties and monitor for changes. Common high-risk clinical areas include behavioral health. Clinical data for behavioral health included de-escalation and emergency response to a behavioral health emergency, facility safety, suicide assessment and prevention, patient monitoring processes, patient death/injury or near miss, staff injury or near miss, and security and disruptive patient handling events and near misses.

A review of a document titled "Standard of Care" showed nursing care would be provided in a safe and therapeutic environment. Measures should be initiated to correct any unsafe environmental conditions seen. Patients should be evaluated for potential harmful items. Provision of adequate staff supervision to ensure the safety of the patient and alteration of the patient's environment if needed to be consistent with the patient's treatment plan.

On 09/11/17 at 10:29 am, surveyors requested policies and procedures for the emergency care and treatment of patients with psychiatric needs. None were provided.

On 09/06/17 of 10:29 am, Officer W stated Patient # 9 was picked up from the ED to transport to a psychiatric facility for further treatment for suicidal ideation. Officer W stated after leaving the ED, when the patient was searched, the patient had a knife.

On 09/07/17 at 4:00 pm, Staff N, RN stated care for psychiatric patient had not been defined at the hospital. Staff N stated at other employers had suicidal / homicidal psychiatric patients were dressed in gowns and were searched for contraband and received 1:1 monitoring and documentation training.

2. Staff Competency
a. Infant / Pediatric Competency
A review of document titled, "Statisical Report 08/17" showed 38 [infant] & pediatric patients were admitted to the inpatient unit from 05/16 to 04/17.

A review of the personnel files of six RN staff showed two different competency checklists were utilized to evaluate a RN competency: "RN Basic Competency", or "Initial ED / Critical Care RN Competency". Both competency checklists failed to contain any infant / pediatric competencies. A review of six medical records of infant/ pediatric patients showed deficient practices in nursing care of infant / pediatric patients regarding IV infusions, weights, intake and outputs, neurology assessment, and fall assessments. (Refer to assessment and monitoring above)

On 09/12/17 at 2:35 pm, Staff B, stated the hospital had no competency regarding the care of infant or pediatric patients.

b. Stroke Competency

A review of log titled, "Emergency Room Register from 08/03/17 to 09/07/17, showed 4 (Patient #10, 47, 47, and 49) of 140 patients presented to the ED with stroke symptoms.

A review of the personnel files showed two different competency checklist were utilized to evaluate a RN competency: "RN Basic Competency", or "Initial ED / Critical Care RN Competency". Both competency checklists failed to contain elements for acute stroke management, treatment including t-PA criteria (dosing, mixing, risk/benefits, exlcusion criteria). On 09/13/17 at 11:20 am, Staff B stated the type of competency completed was based on the nurse's assignment. Staff B stated all RNs were assigned to the inpatient unit and to the ED.

A review of seven RN personnel files showed four (Staff I, K, and V) of seven had a completed "RN Basic Competency" and three ( Staff N, T`, and U) of seven had completed "Initial ED / Critical Care RN Competency".

Review of hospital document titled "Medical/Surgical Emergency Department Competency Verification Form" showed only "TPA" (Tissue Plasminogen Activator also known as the clot-buster) for competency in the administration of thrombolytics for stroke. There was no evidence the elements necessary for the safe administration of TPA were addressed including but not limited to dosing, mixing, administration, risks/benefits education, eligibility/contraindication criteria, assessment and monitoring requirements. There was no evidence for competency assessment for the identification and management of Chest pain, Acute ST Elevation MI tp-A protocol and Retavase Protocol.

Review of American Stroke Association Guidelines titled "Acute Stroke Ready Hospital" dated 9/2013 showed physician and nursing staff should have basic training in acute stroke care with an emphasis in acute stroke care, diagnosis and treatment.

Patient #1 arrived in the ED with a chief complaint of a sudden onset of hand and facial numbness approximately 45 minutes prior to arrival in the ED. Patient was triage 20 minutes after arrival as a Level 2(emergent). Nursing assessment performed and noted no facial weakness, clear speech, partial vision loss to right eye and bilateral hand numbness. Licensed independent provider performed medical screening exam approximately 30 minutes after patient arrival and noted sudden onset of partial visual loss, numbness in hand and generalized weakness reported by patient. On exam provider found right eye visual loss, bilateral hand numbness resolved upon arrival NIHSS score 1 for partial hemianopia. Aspirin 234 mg by mouth given. CT scan of head showed no acute findings. There was no evidence of monitoring by nursing of the patient's neurological status prior to transfer.

Patient #10 arrived in the ED with a chief complaint of slurred speech. Patient was triaged and assigned as a Level 2 (emergent) and brought back into an ED room. There was no evidence in the medical record the registered nurse performed a nursing assessment on the patient and there was no documentation in the patient's medical record. Approximately two hours and 30 minutes after arrival the patient was transferred to another acute care facility for a higher level of care including a neurology consultation. During this time prior to transfer there was no evidence of monitoring by nursing of the patient's neurological status.

On 09/07/17 at 4:33 pm, Staff J stated he/she had only received on the job training for the administration of t-PA and utilizes the dosing chart on the crash cart for help in determining the weight and kilograms for the dosage. Staff J stated the hospital does not have a formal stroke education program for nursing staff that includes acute stroke care and administration of t-PA.

On 09/11/17 at 2:48 pm, Staff J, Director of the Emergency Department (ED) stated there was no training material used for stroke competency of staff or for ED protocol / order sets.


2. Nursing Board Discipline

A review of 8 nursing personnel files showed 1 (Staff K) of 8 (Staff I, K, M, N, S, T, V, & U) nursing staff had past disciplinary action by the OK Nursing Board.

On 09/12/17 at 1:35 pm, Staff A, the CEO, stated the hospital had no policy that addressed the process for managing nurses disciplined by the Board of Nursing. Staff A stated she did not know about the discipline issues for Staff K. Staff A stated the Governing Body had not been informed of Staff K's disciplinary issue.