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Based on review of 10 patient records, hospital's policies and procedures, and other pertinent documentation, it was determined that the hospital was out of compliance with the Condition of Governing Body, as evidenced by failure of the hospital's Governing Body to operate effectively and ensure that the hospital prevented recurrence of the deficient practices identified by OHCQ surveyors during the previous Conditions of Participation (CoP) Survey.


A previous CoP survey, conducted in June 2019, determined the hospital's non-compliance with the Condition of Patient Rights. Identified deficient practices included, in part, the hospital staff allowing general consent forms to be signed by surrogates for patients where no incapacity had been determined and hospital staff's failure to comply with a patient's advanced directive wishes to receive life-sustaining interventions. The plan of correction (PoC) submitted by the hospital on August 7, 2019 outlined corrective actions for the afore-mentioned violations which included staff training and monitoring activities. The implementation of these actions were confirmed by the surveyors during a re-visit on October 17, 2019. Based on review of 9 patient records, staff training records, and audit documentation during the re-visit, the hospital was found to be in substantial compliance with the Condition of Patient Rights.

The current CoP survey on January 7-8, 2020, determined that surrogate decision makers were still allowed to sign consents to procedures and treatments on behalf of patients where no incapacity had been determined/documented in 2 of 10 patient records reviewed (see tag A-0131). In addition, the surveyors also identified one instance in which the hospital staff did not follow a patient's documented advanced wishes for life-sustaining treatment (see tag A-0132).

Based on review of 10 medical records and hospital policies and procedures, it was determined that the hospital failed to ensure that 2 of 10 patients reviewed were allowed to make decisions regarding their treatment plan, as evidenced by multiple treatment and procedural consents signed by the family members of Patients #7 and #8 without any documented evidence that these patients lacked capacity to make decisions or were not able to sign the forms on their own.

Surveyor reviewed the policy titled "Informed Consent", dated 7/2017, which stated: "Section III. The Role of the patient, healthcare agent and surrogate decision maker: D. Consent of a surrogate decision maker, such as a spouse, cannot be substituted for a competent patient's consent except when the patient is incapable of giving consent". Under the "Definitions" section, the policy also stated: "Incapacity: A patient deemed by an attending (and with witness from the appropriate consulting physician as necessary) to lack capacity to participate in the development of the plan of care, including consent to and or refusal of medical and surgical interventions and/or in the planning for care upon discharge from the hospital".

Patient 7 (P7) was an 80+ year old patient who was brought to the hospital by Emergency Medical Services for symptoms of syncope (temporary loss of consciousness/fainting). Documentation by the ED physician and nursing triage personnel stated that the patient was alert and oriented to person, place and time. The informed consent form for treatment was signed by P7's spouse with a notation under "patient unable to sign due to - patient's blood sugar is elevated".

P7 was ordered a GI (gastro-intestinal) consult. An EGD (a procedure during which a scope would be placed in the esophagus to view the upper digestive system) and a colonoscopy (a procedure during which a scope would be placed in the rectum to view the lower digestive system) were both recommended for P7 as a result of the GI consultation. Documentation by the GI physician stated, "Spoke with family at great length. Will speak to family again in the morning", "Family has not made a decision yet about the procedure. If family decides to have the procedures here then we can plan for EGD and colonoscopy in two days".

Another note from P7's medical record determined that the ED physician recommended a blood transfusion based on abnormal lab results; however, it was documented that P7 refused. The physician's note further stated that, after the patient had refused, the patient's adult child was called and a verbal consent was obtained for the blood transfusion over the phone. Both procedure consent forms including the consent for anesthesia, the consent for the blood transfusion and the informed consent were all signed by either the adult child or the patient's spouse.

No documentation was found to support that the patient was unable to make decisions regarding their care or that they had appointed a family member to make decisions for them. Furthermore, no certifications of incapacity were found in the medical record to determine that the patient was unable to make their own healthcare decisions.

Patient #8 (P8) was a 55+ year old patient who was brought to the hospital by Emergency Medical Services from a skilled nursing facility for evaluation and possible replacement of a clogged feeding tube. The patient was non-verbal due to a chronic tracheostomy tube in place for respiratory assistance. Despite being non-verbal, P8 was documented as alert and responsive. Physician documentation stated, "patient has trach in place but is able to nod head yes and no to questions". When questioned about pain and the presence of other symptoms, the patient was able to nod "yes" and "no" appropriately, per the physician.

After evaluation, it was determined that P8 would need a feeding tube replacement. The patient was placed in an observation status and the procedure was scheduled. The consent for the procedure and the Notification of Outpatient Observation Status (NOON) were both signed by the patient's sibling.

Although P8 was non-verbal, no documentation was found to support that the patient would be unable to sign their name, giving consent to treatment and procedures. Furthermore, no documentation was found stating that the patient had appointed a family member to make healthcare decisions for them.

In summary, by allowing the family members of P7 and P8 to sign various consent forms for invasive procedures for P7 and P8 and in the absence of documented evidence of incapacity of the patients, the hospital precluded P7 and P8 from making informed health care decisions.

Based on review of 6 open medical records, 4 closed medical records, policies and procedures, as well as review of the video surveillance footage from November 2019, it was determined that the hospital failed to comply with the documented request of Patient #10 to receive life-sustaining treatment.

Patient # 10 (P10) was a 90+ year old who presented to the emergency department from home via county-operated ambulance with complaints of nausea, vomiting, and respiratory distress. P10's EMS crew arrived at the emergency department at 8:06 pm. P10 had vitals taken by the ambulance crew and remained in the vestibule of the ED entrance with ambulance crew and a family member for 40+ minutes prior to any assessment or evaluation done by the hospital staff. During the 40+ minute wait for the hospital staff to assume care, the ambulance crew were the only practitioners attending to P10's needs, providing P10 with emesis bags, replacing portable oxygen tanks to ensure that the oxygen supply continued, and taking vital signs.

According to the review of video surveillance footage, the ED registered nurse (RN) was seen at P10's stretcher for the first time at 8:51 pm, and soon after, at 8:55 pm, P10 was seen to be taken to a room by RN and the ambulance crew. At that time, P10 was fully visualized on video surveillance and appeared to be alert, moving all extremities, and wearing on a non-rebreather mask on the face.

Further review of the medical record for P10 indicated that P10 was evaluated by an ED physician at
9:26 pm. This provider documented that the patient was unresponsive at the time of the evaluation. The note stated "since arriving [patient] became more somnolent and hypotensive". The note also described a discussion with P10's family: "[family] state that patient did not want heroic measures done, and confirm [patient] is DNR/DNI/comfort care (do not resuscitate/do not intubate) at this time". Following this conversation with the family, the physician anticipated that P10 would pass away in the emergency room. P10 was pronounced dead by the physician at 11:05 pm, after P10's was found to have no pulse or breathing.

While reviewing P10's medical record, the surveyors determined that, at the time of the evaluation by the ED physician, the Maryland Medical Orders for Life-Sustaining Treatment (MOLST) form was on file for P10 and stated that the patient chose "Attempt CPR" option. This meant that the patient desired the life-sustaining measures, such as cardiopulmonary resuscitation and any other medical efforts indicated, to be performed if their heart stopped or if they stopped breathing. This wish was documented and signed by the patient's physician on the MOLST form on 06/09/2019 and was included in the patient's electronic medical record at the hospital. There was no documentation found in P10's record that the provider and family acknowledged the existence of this form at the time of the evaluation at 9:26 pm. There was also no evidence found that the family provided to the hospital an updated form indicating that the patient wanted no "heroic measures" or had a discussion with the physician about the change in P10's wishes from "Attempt CPR" to not wanting any "heroic measures". It appeared that the provider did not identify the presence of or take into account the patient's advanced wishes regarding the life-sustaining treatment documented on the MOLST form. As a result, no life-sustaining measures were attempted when P10's heart and breathing stopped at 11:05 pm.

Based on review of 10 medical records and the emergency department (ED) policies and procedures, interviews with staff, observations of care, tour of the ED, as well as review of video surveillance footage from November 2019, it was determined that the hospital was out of compliance with the Condition of Emergency Services and failed to meet the emergency needs of its patients, as evidenced by:

1) hospital's failure to ensure that, upon arrival to the ED, patients were appropriately and timely triaged/prioritized and assigned an accurate ESI level based on presenting symptoms and vital signs; this resulted in delayed ED physician evaluations of patients #1, #2, and #10 who presented to the ED with potential emergency medical conditions;

2) hospital's failure to staff the Emergency Department (ED) with the number of personnel to appropriately meet patients' needs even after identifying that certain days and times consistently had higher patient volumes (see Tag A-1112).


1) Patient # 10 (P10) was a 90+ year old who presented to the emergency department from home via county-operated ambulance with complaints of nausea, vomiting, and respiratory distress. P10's EMS crew arrived at the emergency department at 8:06 pm, with two other EMS crews already awaiting in the main ambulance area. This resulted in P10 and EMS crew waiting in the vestibule between the two sliding glass doors for over 40 minutes, prior to any hospital nursing or medical staff approaching P10's stretcher.

Review of the medical record for P10 showed that the ED Adult Triage was documented by the triage RN at 8:27 pm and P10 was assigned an ESI level of 3 (meaning P10 was considered to be stable and not requiring an immediate medical treatment). This assessment was not supported by onsite review of video surveillance footage which showed the registered nurse did not approach the patient on the stretcher until 8:51 pm. At that time, P10 and the ambulance crew had been on site for over 40 minutes. During the 40+ minute wait for the hospital staff to assume care, the EMS crew were the only practitioners attending to P10's needs, providing P10 with emesis bags, replacing portable oxygen tanks to ensure that the oxygen supply continued and taking vital signs. At 8:55, P10 was taken to a room and out of the camera's view by the EMS crew and a RN. At that time, P10 was fully visualized on video surveillance and appeared to be alert, moving all extremities, and wearing on a non-rebreather mask on the face.

As mentioned in the previous paragraph, the first blood pressure of 144/81 was documented by hospital's nursing staff at 8:27 pm during the triage process, but since the video did not show nursing caring for the patient at 8:27pm, it was questionable how that blood pressure was obtained. Based on the video and documentation, no other vital signs or physical assessments were performed by the hospital staff at the time of ESI level assignment. The next two blood pressure reading were documented by nursing staff at 9:10 pm with a blood pressure of 89/50, and at 9:20 pm with a blood pressure of 80/54. The ED physician was then notified of the abnormal readings.

P10's was evaluated by the ED physician at 9:26 pm, one hour and twenty minutes after P10 entered the ED. The provider documented at that time: " [patient]...here with nausea/ vomiting and progressive decline in mental status, pt [patient] now hypotensive with unreadable O2 sats [saturation] and unresponsive." Further record review determined that P10 passed away at the facility less than two hours after this evaluation took place.

The ED staff's failure to timely and accurately triage and prioritize P10, resulted in a delayed alert to the ED physician about P10's abnormal vital signs and a delayed evaluation by the ED physician.

Patient #1 (P1) was a 55+ year old who presented to the ED with complaints of chest pain and left arm numbness. Per triage RN documentation, P1 was assigned an ESI level of 3 at 2:05 PM. The initial set of vital signs was documented at 3:11 PM, an hour after the assigned ESI level. P11 waited within the ED for 4+ hours with a complaint of chest pain prior to determination if an emergency medical condition (EMC) existed. P1 was eventually evaluated by a Physician's Assistant (PA) at 6:43 PM, 4+ hours after arrival to the ED, at which time an EKG and relevant bloodwork orders were initiated.

Patient #2 (P2) a 65+ year old presented to the ED with complaints of chest pain, shortness of breath, and coughing up blood. Per triage RN documentation, P2 was assigned an ESI level of 3 at 2:11 PM. The initial set of vital signs was documented at 3:20 PM, an hour after the ESI level was assigned, and included the following abnormal values: heart rate of 105 bpm, respiratory rate of 24 per minute, and a pain score of 10 of 10 for the chest pain.

A brief Emergency Department triage note was entered by a PA at 5:28 PM and stated: "Patient seen in triage. Initial orders placed, further assessment and management per the primary team". Further record review showed that no testing or interventions were initiated until 9:11 pm, despite PA's indicated assessment and plan. P2 continued to wait for 7+ hours after arriving to the ED to be evaluated by the ED physician at 9:20 pm to determine if an EMC existed, at which time an abnormal EKG and lab work results were noted.

In addition to delayed triage and prioritization of the ED patients, a delay was also noted in ordering and obtaining vital tests and procedures that could aid in identifying and ruling out potentially life-threatening conditions for the patients in this ED.

During the tour of the ED on 01/07/20, informal interviews were conducted with the ED staff, including nursing triage personnel. Based on the information obtained during the tour and interviews, it was determined that this ED did not utilize protocols that could be initiated by nursing triage staff for patients who presented with potentially life-threatening symptoms of chest pain, breathing difficulties, and acute mental status changes. If utilized, these protocols would trigger orders for diagnostic testing, procedures, and interventions that could provide the triage personnel with additional information to aid in prioritization of patients and alerting ED providers to the necessity of expedited evaluation. The surveyors were told that these protocols were being developed.

Surveyor reviewed ED staff meeting minutes for the past 12 months. Identified concerns over the previous 8 months included: RN concern's regarding the flow in the ED at night, lengthy wait times to see a provider, and "feels like too much for one provider". The only documented follow-up was to discuss these concerns with the medical chair. Another identified concern was that RNs were not ordering EKG's on all patients with chest pain and shortness of breath. The follow-up was a discussion with the RNs regarding clinical presentation and guidelines for ordering.

2) The hospital also failed to adjust the staffing levels in the Emergency Department (ED) and staff the ED with the number of personnel to appropriately meet patients' needs even after identifying that certain days and times consistently had higher patient volumes. See Tag A-1112.

In summary, the hospital failed to meet the needs of patients in its ED based on the information obtained and reviewed during the survey on January 7 and 8, 2020, which showed a pattern of delayed and inaccurate triage documentation, delayed prioritization and evaluation of patients with potential life-threatening conditions by ED staff, lack of protocols and procedures available to ED staff to aid with triage and prioritization process, and insufficient staffing levels in the ED during the times with high patient volumes.

Based on review of medical records, staff interviews and other pertinent documents, it was determined that the hospital failed to staff the Emergency Department (ED) with the number of personnel to adequately meet patients' needs even after identifying that certain days and times consistently had higher patient volumes.

An interview was conducted on January 7, 2020, at approximately 11:30 a.m., with the Nursing Director of the ED. The Nursing Director reported that their duties included safe staffing, operations, Quality Metrics, and supporting staff. The director stated that staffing for the ED was the same each day and did not go up or down to accommodate the changing patient volumes. The director also stated that the nursing on-call was not utilized; however, a "list of needs" was posted to allow for nurses to sign up voluntarily to 'help out'. When asked if the "list of needs" was effective in accommodating times of higher patient volumes, the director stated, "Most of the time it helps; however, our volumes have increased by 20-30 patients a day in the past month". It was also stated that this increase in daily volumes did not result in changes to the amount of the staff being scheduled.

An interview was conducted on January 8, 2020 at 11:10 a.m. with the Medical Director/Chair of the ED. The Medical Director reported that their duties included employment, staffing, supporting staff, education and working directly with the Nursing Director of the ED. The Medical Director identified known issues in the ED as increased patient volumes with higher acuity levels and the need for updated care spaces. The Medical Director stated that Monday-Wednesday had been consistently identified as higher volume days; however, staffing levels remained the same throughout the entire week.

Surveyor reviewed ED staff meeting minutes for the past 12 months. Identified concerns over the previous 8 months included: RN concern's regarding the flow in the ED at night, lengthy wait times to see a provider, and "feels like too much for one provider". The only documented follow-up was to discuss these concerns with the medical chair. Staffing patterns/challenges, and "feelings that critical care patients and behavioral health patients were a challenge due to staffing and acuity" were discussed several months prior. The follow-up listed was to "set up departmental throughput meeting". Review of the throughput meetings did not reveal discussions/solutions involving staffing patterns/challenges.

Review of two open ED records for patients #1 and #2, who presented during one of the identified higher volume days, revealed delays in triage and provider examinations for the patients with potential emergency medical conditions.

Patient #1 (P1) was a 55+ year old who presented to the ED with complaints of chest pain and left arm numbness. Per triage RN documentation, P1 was assigned an ESI level of 3 at 2:05 PM. The initial set of vital signs was documented at 3:11 PM, an hour after the assigned ESI level. P1 waited within the ED for 4+ hours with a complaint of chest pain prior to determination if an emergency medical condition (EMC) existed. P1 was eventually evaluated by a Physician's Assistant (PA) at 6:43 PM, 4+ hours after arrival to the ED, at which time an EKG and relevant bloodwork orders were initiated.

Patient #2 (P2) a 65+ year old presented to the ED with complaints of chest pain, shortness of breath, and coughing up blood. Per triage RN documentation, P2 was assigned an ESI level of 3 at 2:11 PM. The initial set of vital signs was documented at 3:20 PM, an hour after the ESI level was assigned, and included the following abnormal values: heart rate of 105 bpm, respiratory rate of 24 per minute, and a pain score of 10 of 10 for the chest pain.

A brief Emergency Department triage note was entered by a PA at 5:28 PM and stated: "Patient seen in triage. Initial orders placed, further assessment and management per the primary team". Further record review showed that no testing or interventions were initiated until 9:11 pm, despite PA's indicated assessment and plan. P2 continued to wait for 7+ hours after arriving to the ED to be evaluated by the ED physician at 9:20 pm to determine if an EMC existed, at which time an abnormal EKG and lab work results were noted.