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Based on review of 2 open medical records, 8 closed medical records, updated policies and procedures, staff training materials, internal and external Emergency Department (ED) volume metrics, and other pertinent documentation, observations of care in the ED, interviews with staff and leadership, and review of video surveillance footage of the ED ambulance entrance area, it was determined that the hospital failed to identify and correct the deficient practice of hospital employees relying on non-hospital Emergency Medical Services (EMS) staff to obtain vitals of patients presenting to the Emergency Department (ED). This was evident for 20/21 patients presenting to the emergency room on dates which were reviewed by the surveyors in video footage from the ED.

On August 21, 2020, the surveyor reviewed ED video footage of the hospital ED. In 20/21 presenting patients reviewed, hospital triage staff did not conduct vitals assessment, but rather relied on vital signs assessment data obtained by non-hospital EMS staff and then based triage determinations on that data.

EMS staff are not trained by, not employed by, and not accountable to the hospital. All clinical activities within the hospital were therefore not within the scope of the hospital oversight and quality assurance. Hospital staff reliance on non-hospital staff to collect assessment data and then making triage determinations with that data increased the risk for harm to patients.

Cross Reference Federal Tag A-0397

Based on review of 2 open medical records, 8 closed medical records, policies and procedures, and video surveillance of care provided to 21 patients in the ED ambulance entrance area, it was determined that the hospital's nursing staff relied on non-hospital Emergency Medical Services (EMS) staff vital signs assessment(s) during patient triage. Without conducting the necessary assessment, emergency department triage staff relied on EMS findings in making triage level determinations. For 20 of 21 patients observed in the video footage of the Emergency Room ambulance entrance, the initial assessment of vital signs was confirmed to have been obtained by county-operated EMS (Emergency Medical Services) personnel and not the hospital personnel. The system failure where hospital staff relied on EMS assessment data increased the risk for possible harm to patients.

The term "hospital property" means the entire main hospital campus as defined in §413.65(a), including the parking lot, sidewalk and driveway or hospital departments, including any building owned by the hospital that are within 250 yards of the hospital). Once within the hospital property, the hospital is accountable to provide care and services to meet each patient's needs. (State Operations Manual, Appendix V)

CMS indicates that triage "entails the clinical assessment of the individual's presenting signs and symptoms at the time of arrival at the hospital, in order to prioritize when the individual will be seen by a physician or other qualified medical personnel (QMP)". (State Operations Manual, Appendix V)

Patient # 3 (P3) was an 80+ year old patient who presented to the hospital's Emergency Department via a county-operated ambulance with shortness of breath and reported dizziness in mid-May 2020. Review of the medical record for P3 determined that the initial vital signs documented by the hospital nursing staff on P3's arrival matched the last set of vital signs documented on the EMS run sheet with the addition of a temperature.

Surveyors expanded the survey sample requesting to review the video surveillance footage of the Emergency Room ambulance entrance for the day when P3 presented to the hospital. An offsite review of the 7+ hour video surveillance footage of the day in question, from 2:00 pm until 9:30 pm, was performed by surveyors on August 21, 2020 and included observations of care and assessment provided to P3 and 10 additional patients during 2 shifts, for a total of 11 patients.

Per video footage, upon arrival to the hospital, P3's ambulance crew retrieved the hospital equipment (portable automated vital signs monitor) and took P3's vital signs. The video reflected that, approximately 2 minutes later, there was communication between the EMS crew, the ED nursing staff, and P3; however, no hospital nursing staff was seen taking the initial set of vital signs that was documented by hospital nursing staff in P3's medical record.

Further review of the video footage for the day in question determined that EMS personnel took the initial set of vital signs for 11 out of 11 patients present in the video which corroborated the deficient practice of hospital triage nursing staff failing to assess the patient vital signs and instead relying on assessment by the non-hospital EMS staff. The reviewed time frame covered in the video footage included a shift change to capture ED staff practices on varied shifts. While the second shift Triage Nurse was observed taking the temperature of 2 patients who presented during the second shift, the majority of initial vital sign assessments were still performed by EMS personnel.

Patient #6 (P6) was an 80+ year old individual who presented to the hospital's ED via county-operated ambulance for abdominal issues in early August 2020. The initial arrival vital signs documented in P6's record contained the same blood pressures and heart rate as those in the EMS run sheet.

Surveyors requested to review the second video surveillance footage of the Emergency Room ambulance entrance for the day when P6 presented to the hospital's ED. An offsite review of the 6 hour period on the day in question was performed by surveyors on August 21, 2020 and included observations of care and assessment provided to P6 and 9 additional patients, for a total of 10 patients in this video, and 21 patients across both dated video footage.

Per the second video footage review, an ED triage nursing staff approached and communicated with the ambulance crew and the patient in the first two minutes of P6's arrival in the hospital. Three minutes later, the EMS crew was observed retrieving the hospital's vital sign monitor and taking the initial set of vital signs for P6. During this time, the triage RN was observed in close proximity setting up other equipment.

Further video footage review determined that hospital triage nursing staff performed an initial vital sign assessment for only 1 of 10 patients present in the video, as well as took the temperature of 3 patients. In addition, surveyors observed that ambulance staff were given and applied hospital identification bands on 3 of the 10 patients observed in the video.

With reliance on vital signs obtained by EMS staff, the hospital made determinations of level of risk for triage, which increased the risk for patient harm.

In summary, the hospital's nursing staff failed to ensure hospital staff directly obtained vitals and therefore adequately assessed patients in the emergency department for 20 of 21 ED patients observed in the video footage. Instead, ED nursing staff relied on EMS crews that were not hospital employees for the performance of the initial vital signs assessment.