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Based on interview, documentation in 1 of 1 outpatient and ED record reviewed (Patient 1) and review of policies and procedures it was determined that the CAH failed to fully develop and implement policies and procedures for the provision of outpatient infusion services and ED services to ensure that patient changes of condition were appropriately assessed and managed, that medications were administered in accordance with clear and complete physician's orders, and that the medical record reflected the patient's encounter(s) completely and accurately.

Findings include:

1. Refer to the deficiency cited at Tag C274, CFR 485.635(a)(3)(ii), Standard: Policies and procedures for emergency medical services, that reflects that a patient who experienced a change of condition during the course of a regular scheduled outpatient treatment did not receive ED services and a transfer in accordance with policies and procedures.

2. Refer to the deficiency cited at Tag C296, CFR 485.635(d)(2), Standard: Registered nurse supervise and evaluate, that reflects that RNs failed to appropriately assess and manage a change of condition that occurred during provision of outpatient services, as well as during the the subsequent ED visit.

3. Refer to the deficiency cited at Tag C297, CFR 485.635(d)(3), Standard: Administration of drugs, biological and intravenous medications, that reflects that RNs failed to administer and accurately document an outpatient IV infusion in accordance with clear and complete physician's orders.

4. Refer to the deficiency cited at Tag C302, CFR 485.638(a)(2), Standard: Records complete and accurate, that reflects the medical record did not accurately, clearly and completely describe the patient's outpatient and ED encounters.

Based on interview, documentation in 1 of 1 ED record reviewed (Patient 1) and review of policies and procedures it was determined that the CAH failed to ensure that emergency services were provided and documented, including the refusal of emergency services, in accordance with fully developed written policies and procedures.

Findings include:

1. a. The P&P titled "Provisions of Emergency Medical Services and Purpose and Objectives" dated as effective 03/23/2017 was reviewed and included the following:
* "All patients will receive an evaluation by the Emergency Department Physician."
* "Appropriate tests will be conducted as per the need of the medical condition."
* "Provide initial triage and treatment of all patients."
* "Provide appropriate discharge instructions and follow-up care."
* "Provides for prompt transfer of patients as necessary to an appropriate facility in accordance with transfer agreements, approved trauma system plans, consideration of patient choice, and consent of the receiving facility."
* "Ensure that emergency records are maintained as per regulations."

b. The P&P titled "Emergency Department Nursing Services Standard of Care." dated as effective 03/28/2018 was reviewed and included the following:
* "All patients arriving to the ED will be offered a medical screening exam. Triage assessment can help prioritize the order and urgency of the MSE."
* "The Triage RN should review pertinent pre-arrival information such as alert flags, referrals, EMS information, or other records, if indicated."
* "Quick Triage contains the following components: Chief complaint(s) ... Past Travel/Exposure Screening ... Vital Signs ... Height and Weight ... Pain Assessment ... Patient observations ... Allergy history ... Triage Acuity ... Any focused assessments deemed necessary in order to accurately assessing triage acuity ..."
* "Discharge/Departure Assessment and Vital Signs ... A discharge assessment and vital signs will be done on all patients prior to discharge, transfer, or admission. A discharge/departure assessment should include focused reassessment of pertinent findings based on chief complaint and any abnormality noted in the previous assessment, as appropriate ... LDA removal will be documented in the EHR, as appropriate ... Discharge/departure condition, mobility, and departure mode will be documented."

2. Documentation in the medical record of Patient 1 on 04/16/2019 reflected that he/she presented to the ED at 1742 from an outpatient infusion treatment during which he/she experienced a change of condition. The ED record consisted of the following documentation:
* At 1742 - "Emergency encounter created"
* At 1748 - "Registration Completed"
* At 1751 - The physician recorded a note that reflected "I briefly discussed options with the patient who presented for evaluation of PPROM and contractions. Reports [he/she] has received fluids for contractions today and is concerned for labor, but denies any vaginal bleeding, currently (sic) abdominal pain, trauma or other emergency condition. We discussed urgent evaluation at a birthing center where [he/she] could be monitored for contracts (sic) and fetal heart tones, which cannot be done here."
* At 1753 - "Conditions of Registration" signed by patient

There was no other documentation or other notes in the medical record. There was no evidence of RN triage or vital signs, there was no indication of a physical exam by the physician or any diagnostic testing, there was no indication that the patient was transferred from the ED to another hospital that had OB services for "urgent evaluation," and no documentation to reflect the patient had refused exam and transfer against medical advice. There was no disposition recorded from the ED that included the time patient left and instructions given.

3. An internal, printed email dated 07/25/2019 at 1417 was reviewed and reflected the following information provided by the CAH ED physician on duty at the time of Patient 1's encounter on 04/16/2019:
* The physician received a report about an outpatient who was at the CAH receiving an infusion, who was 26 weeks and five days gestation and reported he/she was "leaking."
* The physician indicated that testing for leaking of amniotic fluid was not something that could be done at the CAH.
* The physician reported that the RNs in the ED felt they could test for amniotic fluid using pH strips, however, the physician stated that at 26 weeks, strips weren't reliable.
* The physician met with the patient upon the patient's arrival to the ED and told him/her that they could "get a workup started but would ultimately need to send you to FBC" and "will need to transfer you."
* The patient "knew it was not in (sic) imminent delivery, wet all the time, more wet right now."
* The patient was "worried about cost" and told the physician that he/she didn't want an MSE or transfer if he/she couldn't be assured there would not be charges for the visit.
* The physician told the patient he/she could not answer that question.
* The patient asked to keep the IV access in place and the physician asked an RN to talk with the patient about that.
* The physician "did cover risks and benefits."

These details that further described Patient 1's ED encounter were not documented in Patient 1's medical record. However, it was still unclear what direction the patient received and where the patient planned to go after he/she left the CAH.

In addition, it was unclear what the CAH's policies and procedures were in relation to examination and testing of pregnant patients to rule out PPROM and labor, in relation to patient's leaving the CAH against medical advice, and in relation to keeping an IV access in place for a patient who was leaving the hospital against medical advice.

4. During interview on 07/25/2019 at 1630 the CNO confirmed that the medical record did not clearly and completely reflect the course of Patient 1's ED encounter on 04/16/2019. The CNO and other staff present at the time stated that the CAH had conducted an investigation and had taken a number of actions in response to this incident to prevent recurrence.

Based on interview, documentation in 1 of 1 outpatient and ED record reviewed (Patient 1) and review of policies and procedures it was determined that the CAH failed to fully develop and implement policies and procedures to ensure the RN supervised and evaluated the provision of nursing care for the patient. The RNs responsible for the care of the patient failed to appropriately assess, manage and document the patient's ordered infusion and change of condition:
* The RNs carried out an incomplete and unclear physician's order and a medication error occurred.
* The RNs failed to assess the patient's reported change of condition.
* The RNs' documentation of the patient's encounter was inaccurate, incomplete and unclear.

Findings include:

1. a. The P&P titled "St Charles Prineville Infusion Room" dated as effective 10/25/2018 was reviewed and included the following:
* "To provide guidelines for the treatment of patients receiving infusion services on the medical floor at St Charles Prineville. This service may include IC infusions, injections, blood transfusions, hydration, port-a-cath care etc."
* "Orders for IV infusion services must be on the Physician Order: Infusion Scheduling form, # 5518 ... All Providers' orders for the infusion room must include: Patient's name, Patient's phone number(s), Date of birth, Insurance information, Diagnosis and CPT code, Orders signed by the Provider, Allergies, DNR status."
* " "Initiating RN is responsible for starting Infusion Room SHARQ Handoff Tool (#5470) and each subsequent nurse is responsible for updating it to include, but not limited to, allergies, home medication list, date labs to be drawn next, date of next dressing change, Central Line catheter measurements, etc."
* "... the RN will ... Document VS before and after infusion."
* "... the RN will ... Document accurate start and stop time for each medication or IV fluid given"
* "A Focused assessment and a brief progress note should be completed with every visit.
* "If a patient experiences any complications, the ordering physician (or hospitalist if unavailable) must be contacted for orders ... The patient, if deemed necessary, will be taken to the ED for further evaluations and treatment by ED provider."
* "Update SHARQ with any pertinent information."
* At the completion of the visit, the nurse will call PAS and instruct them to 'check out' the patient."

b. During interview with the CNO on 07/25/2019 at 1300 he/she stated that the SHARQ Tool was no longer in use at the hospital and had been discontinued when the EPIC EHR system was implemented at the hospital.

c. The P&P titled "Emergency Department Nursing Services Standard of Care." dated as effective 03/28/2018 was reviewed and included the following:
* "All patients arriving to the ED will be offered a medical screening exam. Triage assessment can help prioritize the order and urgency of the MSE."
* "The Triage RN should review pertinent pre-arrival information such as alert flags, referrals, EMS information, or other records, if indicated."
* "Quick Triage contains the following components: Chief complaint(s) ... Past Travel/Exposure Screening ... Vital Signs ... Height and Weight ... Pain Assessment ... Patient observations ... Allergy history ... Triage Acuity ... Any focused assessments deemed necessary in order to accurately assessing triage acuity ..."
* "Primary Nursing Assessment ..."
* "Ongoing Reassessment ..."
* "Discharge/Departure Assessment and Vital Signs ... A discharge assessment and vital signs will be done on all patients prior to discharge, transfer, or admission. A discharge/departure assessment should include focused reassessment of pertinent findings based on chief complaint and any abnormality noted in the previous assessment, as appropriate ... LDA removal will be documented in the EHR, as appropriate ... Discharge/departure condition, mobility, and departure mode will be documented."

2. The outpatient infusion medical record for Patient 1's encounter on 04/16/2019 was reviewed and included the following information:

a. The only order signed by a physician in the record was a copy of a handwritten physician's prescription pad form. It was dated 03/12/2019 and reflected "1 Liter Lactated Ringer 1 - 2 per week as needed for recurrent N/V dehydration in pregnancy." The order did not include all information required by the "Infusion Room" P&P identified under Finding 1 above such as the patient's phone number(s) and allergies and DNR status. Further the order for the actual infusion itself was not complete and did not include the rate or duration of the infusion.

b. The outpatient record, including a "Patient Care Timeline" reflected the patient's encounter consisted of the following events:
* At 1451 - Patient 1 arrived at hospital and registered as an outpatient for IV infusion.
* At 1458 - RN A recorded and "electronically signed" under "Medications - All Orders ... lactated Ringer's bolus 1,000 mL ... Once 04/16/19 1500 - 1 occurrence"
* At 1505 - RN B recorded vital signs and "Pain Assessment ... No/denies pain"
* At 1515 - RN B recorded IV access was placed in Left Antecubital by RN A.
* At 1515 - RN B's entry on the "Timeline" reflected "Medication New Bag - lactated Ringer's bolus 1,000 mL - Dose: 1,000 mL ; Rate: 600 mL/hr ; Route: Intravenous ... Scheduled Time: 1500"
* At 1516 - RN B's entry under "All Meds and Administrations" reflected "New Bag - 1,000 mL - 600 mL/hr - 20 Minutes ..."
* At 1536 - The next entry in the record was recorded by RN C on the "Timeline" and reflected "Medication Stopped - lactated Ringer's bolus l,000 mL ... Scheduled Time: 1536"
* At 1536 - RN C's entry under "All Meds and Administrations" reflected "Stopped - 0 mL - 0 mL/hr - 20 minutes ... "
There were no further entries recorded until 1717.
* At 1717 - RN C recorded vital signs and "Pain Assessment ... 1 ...cramping"
* At 1723 - RN C recorded the only narrative note in the outpatient record. The note reflected "Pt reports that [he/she] can feel the fetus moving and that [he/she] has a cramping sensation (like heavy period cramps), no bloody discharge noted. Reports extra moisture in vaginal area unknown source. Per RN report, pt is to report to ED after fluids."

c. There was no other documentation in the outpatient record of Patient 1 for the 04/16/2019 encounter. There were no other notes, there was no documentation to reflect the time the patient began to complain about "cramping," who he/she complained to, that an assessment was conducted, that the RNs contacted the physician, and what the patient was told and by whom. There was no explanation for what occurred during the encounter between 1536 when the infusion "stopped" and 1717, over an hour and a half later, when vital signs were taken. It was not clear when RN C wrote "no bloody discharge noted" whether the RN had examined the patient, nor was it clear who and what "Per RN report" meant. There was no assessment of condition or status at the end of the patient's encounter, there was no disposition from outpatient services that included the time the patient left, instructions given, where the patient was discharged to, etc.

d. The electronic MAR reflected the following "Completed Medications:"
- "lactated Ringer's bolus 1,000 mL : Dose 1,000 mL : 3000 mL/hr : Intravenous : Once
- Ordered Admin Amount: 1,000 mL
- Frequency: Once
- Order Dose: 1,000 mL
- Ordered Infusion Rate: 3,000 mL/hr
- Infused Over: 20 minutes
- Recent Actions: 04/16 1516 NewBag - 04/16 1536 Stopped"
There was no documentation to reflect from where and by whom the "Ordered Infusion Rate" was generated.

e. The medical record entries at 1515 and 1516 by RN B reflected "... Dose: 1,000 mL ... Rate: 600 mL/hr ... " inconsistent with the MAR rate recorded under Finding 2.d. above. The documentation reflected that a medication error occurred as 1,000 mL infused at a rate of 600 mL/hr would equal an infusion duration of one hour and forty minutes. That is versus the "20 minutes" RNs B and C documented in the medical record as the time the infusion ran, or the "two hours" that RNs B and C indicated during interviews that the infusion actually ran. However, the exact nature of the error was unknown as the original order did not include the infusion rate and the medical record documentation was not accurate.

3. The next documentation in the EPIC EHR for Patient 1 on 04/16/2019 was a record of a brief ED encounter.

a. The ED record, including an ED "Patient Care Timeline" reflected the following events during the patient's ED encounter:
* At 1742 - "Emergency encounter created"
* At 1748 - "Registration Completed"
* At 1751 - The physician recorded a note that reflected "I briefly discussed options with the patient who presented for evaluation of PPROM and contractions. Reports [he/she] has received fluids for contractions today and is concerned for labor, but denies any vaginal bleeding, currently abdominal pain, trauma or other emergency condition. We discussed urgent evaluation at a birthing center where [he/she] could be monitored for contracts (sic) and fetal heart tones, which cannot be done here."
* At 1753 - "Conditions of Registration" signed by patient

b. There was no other documentation or other notes in the record. There was no evidence of RN triage or vital signs, there was no indication of a physical exam by the physician, there was no indication that the patient was transferred from the ED to another hospital that had OB services for "urgent evaluation," and no documentation to reflect the patient had refused exam and transfer against medical advice. There was no disposition recorded from the ED that included the time patient left and instructions given, etc.

4. The EPIC EHR reflected that the patient did arrive at St. Charles Redmond later that evening. The documentation reflected that an RN from St. Charles Redmond hospital recorded that the Left Antecubital IV access placed by RN A at St. Charles Prineville at 1515 was removed at 2127 by St. Charles Redmond staff.

The St. Charles Prineville medical record documentation by the RN who discharged the patient from outpatient services as described under Finding 2 above did not reflect that the patient left there with an IV access still intact nor why it had not been discontinued.

5. During interview with RN B on 07/25/2019 at approximately 1430 he/she confirmed that he/she had been involved in care of Patient 1 on 04/16/2019. Information provided by RN B included the following:
* RN B stated that it was his/her first encounter with Patient 1, and that he/she was "not the primary nurse" for the patient as RN B was orienting with RN A who performed the "majority of care and documentation."
* RN A inserted the IV with RN B's assistance and started the infusion.
* At about the time the infusion was started the patient complained of "stomach cramps" and mentioned that he/she had a "terrible" previous pregnancy that included N/V.
* RN A told the Patient that he/she had been an RN in the FBC at St. Charles Redmond hospital and that "With the cramping you're having you might want to call your OB."
* The infusion continued and RN B stated that the patient did not appear to be in distress.
* RN B stated that his/her shift was scheduled to end at 1715 and the prior to that time Patient 1 informed the RNs that he/she had called the OB and "[Patient 1] let us know that [his/her] OB said after your infusion go get checked out in ER."
* RN B stated that at 1645 RN A and him/herself "gave report" to the oncoming RN C and told RN C that the patient had informed them that his/her OB had directed the patient to go to the ED when the infusion was over.
* RN B stated that the infusion was still running when he/she reported off duty.
* RN B stated that the patient was "very particular about the infusion running over two hours" and that the "Patient said it's supposed to be over two hours."
* RN B stated that "usually" orders for "bolus" means the infusion is to be administered "in and out," but that he/she had looked back at Patient 1's prior visits and "everyone was giving it over two hours."
* RN B stated that he/she did not recall any details or assessment of the "cramping" the patient complained of.
* RN B confirmed that he/she did not document or record any of these interactions with Patient 1.

6. During interview with the CRM on 07/25/2019 at 1510 he/she stated that RN C had been interviewed and had provided information that included the following:
* RN C stated that Patient 1 had spoken to his/her doctor who told her to go to the ED after the infusion was completed.
* RN C said that after the infusion he/she took the patient to the ED in the staff elevator and to the patient registration area.
* The RN stated that the patient didn't want to go to the registration area because his/her pants were "wet."
* The patient told the RN that he/she wanted to go home to change clothes so the RN gave the patient a sanitary napkin.

7. All three RNs involved in the care of Patient 1 failed to assess and manage the patient's care appropriately and failed to document the care and services provided completely and accurately.

8. During interview on 07/25/2019 at 1630 the CNO confirmed that the medical record did not clearly and accurately reflect the administration of the infusion orders and the course of Patient 1's outpatient and ED encounter on 04/16/2019. The CNO and other staff present at the time stated that the CAH had conducted an investigation and had taken a number of actions in response to this incident to prevent recurrence.

Based on interview, documentation in 1 of 1 outpatient record reviewed (Patient 1) and review of policies and procedures it was determined that the CAH failed to fully develop and implement policies and procedures to ensure the RN administered drugs in accordance with physician's orders. The RNs responsible for the care of the patient carried out a physician's order that was incomplete and unclear and did not document the administration of the infusion as it occurred.

Findings include:

1. Refer to the deficiency cited at Tag C296, CFR 485.635(d)(2), Standard: Registered nurse supervise and evaluate, that reflects that RNs failed to administer an IV infusion in accordance with clear and complete physician's orders and failed to accurately document the administration of the infusion.

Based on interview, documentation in 1 of 1 outpatient and ED record reviewed (Patient 1) and review of policies and procedures it was determined that the CAH failed to fully develop and implement policies and procedures to ensure that the medical record reflected the patient's encounter(s), and the provision of care and services, accurately, clearly and completely.

Findings include:

1. Refer to the deficiencies cited at Tag C274, CFR 485.635(a)(3)(ii), Standard: Policies and procedures for emergency medical services, and Tag C296, CFR 485.635(d)(2), Standard: Registered nurse supervise and evaluate, that reflects that CAH staff failed to accurately, clearly and completely document the patient's outpatient and ED encounters, and the care and services provided, including the administration of an IV infusion.