HospitalInspections.org

Based on observational tours, review of medical records, ambulance trip report review, facility Policy and Procedure review, Emergency Department Log review, Facility timeline of events review, credentialing file review, staffing schedules review, E-mail communications review, and annual competency training reviews and staff interviews it was determined the facility failed to ensure that an appropriate medical screening examination, within the capability of the hospital's emergency department was provided by a qualified medical provider and failed to ensure continued monitoring of an individual's needs after it was identified by staff from the cardiac monitor of an abnormal oxygen saturation and lethal cardiac arrhythmia for 1 (#1) of 20 sampled medical records reviewed.


Cross reference to A-2406 as it relates to failure to provide an appropriate medical screening examination.

Based on observational tours, review of medical records, ambulance trip report review, facility Policy and Procedure review, Emergency Department Log review, facility timeline of events review, credentialing file review, staffing schedules review, e-mail communications review, annual competency training reviews, and staff interviews, it was determined the facility failed to ensure that an appropriate medical screening examination, within the capability of the hospital's emergency department was provided by a qualified medical provider and failed to ensure continued monitoring of an individual's needs, after an abnormal oxygen saturation level and lethal cardiac arrhythmias from the cardiac monitor were identified by staff for 1 (#1) of 20 sampled medical records reviewed.

Findings were:

1. Observational Tour
An observational tour of the Emergency Department (ED) and Labor and Delivery Department was conducted on 9/24/18 at 11:30 a.m. to 12:00 noon accompanied by the Accreditation Coordinator and Employee #1. Observed EMTALA signage displayed prominently in all patient access areas. Observation of the ED monitoring station revealed an alarm tech monitoring two (2) screens. A total of twelve (12) patients were observed to be monitored on the alarm screens. The tech was actively calling nurses regarding various patient's statuses.

2. EMS Ambulance Report
The EMS ambulance trip report dated 9/14/2018 was reviewed. The report revealed in part, "Vital signs: 1546 B/P (Blood Pressure) 138/92; P (pulse) 82; Respirations: 16; Pulse Ox: 92%; Blood Glucose: 106 ...Pain Level: 10... Narrative ...MED2 responded immediately to (Patient #5) complaining of weakness and diarrhea ...the patient is awake, alert and oriented to person, place, time and event. The patient stated that she has been having diarrhea for a few months now and the Doctor hasn't been able to determine the cause but in the last two days it has gotten worse and now is unable to stand and walk. The patient states she has been having uncontrollable diarrhea since yesterday evening ...The patient was asked what hospital she would like to go to for further evaluation and the patient advised EMS to go to Phoebe Main ...the patient and her vitals were monitored en-route to Phoebe Main. Upon arrival. The patient was placed in a room, and report was given to ...RN."

3. Central Log Review
A review of the facility's central log revealed that Patient #1 presented to the Emergency Department (ED) via ambulance on 09/14/18 at 4:20 p.m.

4. Medical Record Review Patient #1
Review of Patient #1's medical record revealed that he/she arrived at the facility via ambulance with complaints of weakness and persistent diarrhea. A nursing assessment at 4:29 p.m. revealed that Patient #1 was awake, responsive, and oriented, had no difficulty breathing, reported no pain, and his/her skin was warm with normal color. The nurse assigned an Emergency Severity Index (ESI) level (level assigned to indicate how critical a patient is) of three (3) to Patient #1. At 4:29 p.m., Patient #1's vital signs were as follows:
Temperature 98.1 degrees (normal range 97.7-99.5 °F),
Heart rate - 78 beats per minute (normal range 60 to 100 beats per minute), Respirations- 20 breaths per minute (normal range 14 to 20 breaths per minute), blood pressure- 138/90 (normal 120/80), oxygen saturation- 99% (normal range is 95-100%).
Further review of Patient #1's record revealed that Patient #1 had blood drawn for laboratory tests and had an intravenous (IV) line placed in his/her left arm at 4:47 p.m. At 4:50 p.m., Patient #1's vital signs were as follows:
Heart rate - 76 beats per minute,
Respirations- 20 breaths per minute, and
Oxygen saturation- 97%. Patient #1 was on a continuous cardiac monitor (a monitor that continuously records heart rate, respiration, and oxygen saturation). Review of the patient care notes revealed that the respiratory therapist (Employee #2) responded to Patient #1's room at 5:34 p.m. in response to a family member calling for help. Employee #2 found Patient #1 unresponsive, pulseless and initiated a code blue. Review of the code blue documentation revealed that cardiopulmonary resuscitation (CPR) was started at 5:35 p.m. At 5:37 p.m., the patient was in asystole ('flat line', no cardiac activity) and received a dose of epinephrine (a medication used to increase the heart rate) via intravenous (IV) line (a small plastic tube inserted in the vein to give medicine and IV fluids). The documentation revealed that at 5:39 p.m. Patient #1 remained in asystole. At 5:40 p.m., Patient #1 was given a dose of epinephrine via IV. Patient #1 remained in asystole and at 5:43 p.m. he/she was given another dose of epinephrine. Patient #1 remained in asystole and was given epinephrine at 5:46 p.m. and 5:49 p.m. At 5:50 Patient #1 's cardiac rhythm showed ventricular fibrillation (abnormal heart rhythm) and received defibrillation (an electrical shock to help the heart start). At 5:52 p.m. Patient #1's cardiac rhythm was asystole. Resuscitation efforts were stopped at 5:52 p.m.
Review of the physician's (Credential #5) note revealed that he/she was called to Patient #1's room at 5:35 p.m. and found Patient #1 unresponsive, apneic (not breathing) and without a pulse. CPR was in progress, and a breathing tube was inserted. A bedside ultrasound was used and determined that there was no cardiac activity present. Patient #1's time of death was 5:52 p.m.

5. Facility Timeline of Events
A review of the timeline of events provided by the facility revealed as follows:
4:20 p.m.- Patient #1 arrived at the facility via EMS and was placed in a room immediately.
4:29 p.m.- Patient #1 was triaged by RN#3, Patient #1's primary nurse. Patient #1's chief complaint was diarrhea for six (6) months, worse over the past two (2) days. Patient #1's triage vital signs were stable, and Patient #1 was noted to be awake, alert and talking.
4:35 p.m.- Patient #1 was placed on a cardiac monitor.
4:36 p.m.- RN #3 inserted an IV and drew blood for laboratory tests.
4:50 p.m.- The cardiac monitor showed that Patient #1 had an oxygen saturation of 64%. The record revealed that no one responded to Patient #1's room at that time.
4:53 p.m.- The monitor alarm was silenced from the Central Monitoring Station.
4:54 p.m.- The monitor showed that Patient #1 was in ventricular tachycardia (abnormally rapid heart rate) for three (3) seconds.
4:54 p.m.- The monitor alarm was silenced from the Central Monitoring Station three (3) consecutive times.
4:55 p.m.- The monitor showed that Patient #1 was in ventricular tachycardia and alarmed with a red alarm. The monitor technician notified Patient #1's primary nurse. The primary nurse reported that Patient #1 was 'okay and moving' and that he/she would check on him/her 'in a minute'.
4:55 p.m.- The monitor was silenced from the Central Monitoring Station three (3) consecutive times.
4:56 p.m.- The monitor showed that the patient was in ventricular tachycardia from 4:55 p.m. through 5:00 p.m.
5:00 p.m.- Ventricular tachycardia and ventricular fibrillation (erratic and disorganized heart rhythm - emergency requires immediate attention) were noted on Patient #1's monitor. Patient #1's oxygen saturation was 69%.
5:01 p.m.- The monitor showed that Patient #1's rhythm changed from ventricular fibrillation to asystole. The alarm was silenced from the Central Monitoring Station.
5:02 p.m. to 5:04 p.m.- The apnea alarm was noted on the monitor.
5:04 p.m.- The alarm was silenced from the Central Monitoring Station.
5:06 p.m.- The monitor showed ventricular fibrillation and changed to asystole. The alarm was silenced at the Central Monitoring Station.
5:07 p.m. to 5:32 p.m.- The monitor showed asystole. The alarm was silenced from the Central Monitoring Station nine (9) times.
5:32 p.m.- Patient #1 was found by a family member. A code blue was called, and the monitor was placed in 'standby' mode from Patient #1's room. CPR and ACLS protocol were started and Patient #1 expired at 5:52 p.m. on 09/14/18. The facility failed to follow their policies and procedures as evidenced by: -
Patient #1 manifested a medical condition of acute symptoms of sufficient severity, weakness, and persistent diarrhea while in the ED;
The cardiac monitor revealed multiple life-threatening cardiac arrhythmias, (an emergency medical condition);
Patient #1's oxygen saturation level dropped to 64% (normal range 95%-100%);
Patient #1 required immediate attention for her impairment of bodily functions once the abnormal vital signs and lethal cardiac functions were known.

Despite the tech notifying the RN of abnormal cardiac arrhythmias and the drop in the patient's oxygen saturation, Patient #1 did not receive a visual re-assessment by the RN as stated in the facility's policy. Additionally, the RN failed to manually confirm the abnormal vital signs provided by the automated monitoring equipment as stated in the facility's policy and procedure. The tech also failed to communicate/escalate to the Charge Nurse and/or the physician immediately of abnormal vital signs and lethal cardiac arrhythmias, after the nurse failed to reassess the patient on the critical findings that were displayed on the monitor. Patient #1 expired on 9/14/2018 at 5:52 p.m.


6. Interviews
During an interview with the Emergency Room (ED) Manager (RN #1) on 09/24/18 at 11:55 a.m. in the ED, the ED Manager explained that ED Technicians (techs) were all trained to monitor the alarms in the ED. He/she stated that none of the techs were qualified to interpret rhythms but were trained to distinguish between types of alarms that were triggered. The ED Manager stated that one tech was responsible for monitoring all the alarms and that the charge nurse was responsible for making the assignment. The ED Manager further stated that the alarms are monitored twenty-four (24) hours a day, seven (7) days a week. The Manager explained that a red alarm indicated any fatal, or potentially fatal, vital signs or arrhythmias. If a red alarm triggered, the tech was responsible for notifying the nurse by radio communication of the alarm and what had happened to trigger the alarm. The nurse had sixty (60) seconds to respond to the communication. If the alarm is not taken care of within sixty (60) seconds, the tech is supposed to notify the ED Charge Nurse. All nurses are expected to respond to an alarm, whether the patient is theirs or not. The ED Manager added that all nurses are expected to respond to any alarms in their patient's room. The ED alarm monitor is there as a back-up in case the nurse is caring for another patient in another room and can't hear or respond immediately to the alarm. The ED Manager stated that the ED monitor techs are covered during their meal and breaks.
During a follow-up interview with the ED Manager (RN #1) on 09/24/18 at 4:20 p.m. in the Conference Room, the ED Manager acknowledged that the facility's ED alarm policy was not followed by the RN #3 and the tech (Employee #4). The ED Manager added that RN #3 should have gone to Patient #1's room and assessed Patient #1 after the tech notified RN #3 that the patient's red alarm had triggered. The ED Manager added that the tech did not follow the alarm policy by notifying the Charge Nurse after sixty (60) seconds when the RN did not respond to Patient #1's room. ED Manager indicated that he/she was working the 7:00 a.m. to 7:00 p.m. shift on 09/14/18 and was present in the alarm monitoring station when the code was called for Patient #1. ED Manager revealed that he/she saw on the monitor that the alarm had been silenced in Patient #1's room. He/she elaborated that when the alarm was silenced at the monitoring station, this also silenced the alarm at Patient #1's bedside. The ED Manager stated that he/she spoke with both RN #3 and Employee #4 after the code and learned that Employee #4 had communicated to RN #3 multiple times that Patient#1's red alarm had triggered. Employee #4 had reported to the ED Manager that RN #3 stated that RN #3 had just been in Patient #1's room, and that Patient #1 "was fine", and that RN #3 would take care of Patient #1 "shortly". The ED Manager stated that Employee #4 confirmed that Employee #4 did not call the charge nurse to report the red alarm per the facility's ED protocol. The ED Manager stated that RN #3 and Employee #4 were sent home and suspended immediately and subsequently terminated on 09/19/18 as a result of the incident. The ED Manager stated that the facility became aware of Patient #1's decline in status when Patient #1's family entered Patient #1's room and found Patient #1's unresponsive. The ED Manager indicated that Patient #1's family immediately sought help for Patient #1, and a code blue was called. The ED Manager stated that it appeared that Patient #1 was down for possibly thirty (30) minutes before CPR was initiated. The ED Manager stated that he/she notified the monitor vendor the next day, and the settings that allowed the techs to silence the alarms from a remote location was disabled. The ED Manager stated that the alarm could only be silenced from the bedside and as part of the new ED practice, the alarm can only be silenced by licensed clinical staff. The ED Manager stated that the ED staff was made aware of the policy changes regarding the alarm settings, and the staff was re-educated about responding to the alarms and patient condition escalation status.

During a telephone interview with the Respiratory Therapist (Employee #2) on 09/25/18 at 8:47 a.m., Employee #2 stated that he/she worked the 7:00 a.m. to 7:00 p.m. shift on 09/14/18. Employee #2 recalled Patient #1 due to the circumstances related to Employee # 's involvement in Patient #1's care on 09/14/18. Employee #2 explained that he/she was in another patient's room that was directly across from Patient #1's room when he/she heard someone calling out for help. Employee #2 ran out of the room and into the hallway and saw someone yelling outside of Patient #1's room that Patient #1 was in distress. Employee #2 recalled that upon entry into Patient #1's room, Patient #1's face and hands were blue, and Patient #1 was unresponsive and pulseless. Employee #2 called a code and began Cardio Pulmonary Resuscitation (CPR) on Patient #1. Employee #2 stayed and assisted with CPR for approximately ten (10) minutes until Patient #1 was pronounced expired by the ED Medical Doctor (MD). Employee #2 stated that he/she believed that CPR was performed for only a short period because it appeared that Patient #1 had been expired for an extended period of time. Employee #2 stated that his/her understanding of the alarm system was limited. Employee #2 stated that the ED techs are all trained to notify the nursing staff by radio if a patient's alarm goes off. Employee #2 revealed that he/she was not knowledgeable about the differences between a red or yellow alarm, or what different alarms represented concerning patient status.

During an interview with the ED Medical Doctor (MD #5) on 09/25/18 at 9:36 a.m. in the Conference Room, MD #5 stated that he/she was working on 09/14/18 and remembered Patient #1. MD #5 stated that Patient #1 had not yet been assigned to a practitioner, but the patient had been assigned a bed, and labs were drawn per the ED protocol for nausea, vomiting, and diarrhea. MD #5 stated that the results of the laboratory tests been received at the time of Patient #1's decline in status. MD #5 explained that Patient #1's vital signs were stable on admission to the ED and added that if a patient came in with unstable vitals, or in apparent distress, the patient is seen immediately by a practitioner. MD #5 stated that it is not unusual for a nurse to report that a patient's condition had changed, and a practitioner would respond directly to the patient's bedside. MD #5 stated that all of the necessary tests had been ordered for Patient #1 to help determine what was going on with the patient clinically. MD #5 recalled being made aware that a code blue was called for Patient #1, and MD #5 responded Patient #1's bedside immediately. On assessment, Patient #1 was pale and without pulse or respirations. CPR was in progress. MD #5 could not ascertain how long Patient#1 had been without pulse or respirations. MD #5 further stated that the code ran for approximately seventeen (17) minutes. A cardiac ultrasound was utilized at the bedside to confirm that there was no cardiac activity. MD #5 stated that it would not have been clinically indicated to continue with CPR based on the patient's clinical status.

During an interview with the ED Charge Nurse (RN #6) on 09/25/18 at 2:51 p.m. in the Conference Room, RN #6 stated that RN #6 was working the 7:00 a.m. to 7:00 p.m. shift on 09/14/18. RN #6 recalled that he/she was at the alarm station speaking with the tech (Employee #4) when another tech approached RN #6 and stated that Patient #1 was actively coding. RN #6 stated that he/she did not hear any active alarms while RN #6 was at the alarm station. RN #6 explained that when a red alarm is triggered, it makes a distinct, high-pitched sound, and RN #6 would have heard the alarm unless the alarm was silenced. RN #6 went to Patient#1's room and observed that Patient#1 was receiving CPR. RN #6 stated that part of his/her responsibilities was to make the clinical assignments in the ED. RN #6 stated that he/she assigned the tech (Employee #4) to the ED alarm station. RN #6 added that it was her practice to rotate the alarm assignment every four (4) hours. RN #6 stated that she expected that the nurses answer all red alarm notifications immediately and within sixty (60) seconds. RN #6 stated that if the primary nurse is unable to respond to a red alarm, the RN is expected to ask another nurse to respond or to contact the charge nurse. RN #6 stated that she expected the techs to notify the charge nurse if the primary nurse had not answered a red alarm notification within sixty (60) seconds.


7. Policy and Procedures
A review of the facility policy, entity PPMH, "EMTALA", last reviewed 03/13/17, revealed that the Medical Screening Examination ("MSE") is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether or not an Emergency Medical Condition existed, or a woman is in labor. Screening is to be conducted to the extent necessary, by physicians and/or other Qualified Medical Person or Personnel (QMP) to determine whether an Emergency Medical Condition exists. With respect to an individual with psychiatric symptoms, an MSE consists of both a medical and psychiatric screening.
Emergency Medical Treatment and Active Labor Act ("EMTALA") refers to Sections 1866 and
1867 of the Social Security Act, 42 U.S.C. Section 1395dd, which obligate hospitals to provide medical screening, treatment and transfer of individuals with Emergency Medical Conditions or women in labor.
It is also referred to as the "anti-dumping" statute. As a not-for-profit community hospital, PPMH provides treatment to patients regardless of their ability to pay, and therefore its core mission as well aligned with its EMTALA obligations.
(1) the term "emergency medical condition" means-
(A) a medical condition manifesting itself by acute symptoms of sufficient severity (including
severe pain) such that the absence of immediate medical attention could reasonably be
expected to result in-
(i) placing the health of the individual (or, with respect to a pregnant woman, the health
of the woman or her unborn child) in serious jeopardy,
(ii) serious impairment to bodily functions, or
(iii) serious dysfunction of any bodily organ or part; or
(B) with respect to a pregnant woman who is having contractions-
(i) that there is inadequate time to effect a safe transfer to another hospital before delivery, or
(ii) that transfer may pose a threat to the health or safety of the woman or the unborn child.
Continued review of the policy revealed that "stabilize" means, with respect to an Emergency Medical Condition to either provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of an individual from a facility or, in the case of a woman in labor, that the woman has delivered the child and the placenta. Exception applicable to inpatients: If a hospital has screened an individual and found that the individual has an Emergency Medical Condition and admits that individual as an inpatient in good faith in order to stabilize the Emergency Medical Condition, the hospital has satisfied its special responsibilities with respect to that individual under EMTALA. Stabilized with respect to an Emergency Medical Condition means that no material deterioration of the condition is likely within reasonable medical probability, to result from or occur during the transfer of the individual from the facility or in the case of a woman in labor, that the woman delivered the child and the placenta.
A review of the facility policy, entity PPMH, "Emergency Center Assessment and Reassessment", last reviewed 01/01/17, revealed that assessment involves a brief, rapid assessment to identify actual or potential, life-threatening illness or injury related to:
Airway
Breathing
Circulation
Disability - GCS (Glasgow Coma Scale) AVPU (alert, verbal, pain, unresponsive)
A secondary survey involves a more focused and detailed evaluation of the patient to identify other, less severe, non-life-threatening, illness or injury. After the ABCD's have been addressed, the following should be obtained:
Vital signs: a complete set of vital signs, when clinically indicated, including pulse oximetry, orthostatic and pain scale, should be obtained.
Head-to-toe assessment of body systems, when clinically indicated. The assessment may be focused on only the area of the complaint, or the entire body.
Cardiac rhythm: When clinically indicated (i.e.: chest pain, arrhythmia), an EKG should be obtained and monitor strip mounted on the nurse's notes as a baseline and whatever significant changes in rate, rhythm or ectopy occur.
Glasgow Coma Scale (GCS): should be obtained on all patients when clinically indicated (i.e.: head trauma, altered mental status). All trauma patients require an admission GCS.
Last menstrual period: should be obtained on all female patients of childbearing age, when clinically indicated (i.e.: abdominal pain, vaginal bleeding).
Immunization history (specifically last tetanus) should be obtained on all patients, when clinically indicated (i.e.: laceration, all trauma patients).
Weight: should be obtained on all pediatric patients and any patients requiring medications with weight-based dosing (i.e.: rabies immunizations, heparin). Weight should be actual (by scale), not estimated/stated weight.
Head circumference: should be obtained on children < 12 months when clinically indicated (i.e.: hydrocephalus, failure to thrive).
Visual acuity: should be obtained when clinically indicated.
Past medical and surgical history: any significant medical or surgical history should be ascertained and documented in the chart.
Current medications: A complete list of the patient's medications, including over the counter and herbal/natural remedies should be documented in the chart.
Allergies: A complete list of the patient's allergies should be listed in the chart.
A further review revealed that the frequency of reassessment is a guideline based on the patient's ESI score.
ESI Level 1 = No less than every hour for four (4) hours, then every two (2) hours.
ESI Level 2 = No less than every hour for two (2) hours, then every two (2) hours.
ESI Level 3 = No less than every two (2) hours for four (4) hours, then every four (4) hours.
ESI Level 4 & 5 = every four (4) hours, or as directed by the physician.
Abnormal vital signs provided by automated equipment will be confirmed manually. Abnormal vital signs resulted will be communicated to the physician/provider immediately and documented in the patient's medical record.
Vital signs are defined as obtaining the blood pressure, heart rate, respiration, temperature, pulse oximeter, pain and mental status as appropriate.
The frequency of the reassessment is based on the patient's acuity, condition, history, and complaint, or as directed by the physician and nurse/or nurse.
Vital sign results will be communicated to the primary nurse/designee and documented in the patient record.
A continued review revealed that a focused assessment related to the chief complaint shall be accomplished with every change of primary caregiver; e.g. change of shift or as clinically indicated. Any deterioration in condition will be reported to the physician.
A review of the facility's alarm parameters in the ED revealed:
The monitor indicated a red alarm with:
Heart rate greater than one hundred forty-five (145) beats per minute or lower than thirty-five (35) beats per minute.
Arrhythmia- asystole, ventricular fibrillation, ventricular tachycardia for sustained for greater than four (4) seconds. Ventricular tachycardia with a heart rate greater than one hundred (100) beats per minute. a Ventricular tachycardia runs greater than five (5) seconds. Supraventricular tachycardia with a heart rate greater than one hundred eighty (180) beats per minute.
Oxygen saturation- pulse oximetry lower than eighty (80) percent.
Respirations- apnea longer than twenty (20) seconds.
The monitor indicated a yellow alarm for:
Heart rate greater than one hundred twenty-five (125) beats per minute and lower than fifty (50) beats per minute.
Oxygen saturations- pulse oximetry lower than ninety (90) percent.
Blood pressure- systolic blood pressure greater than one hundred eighty (180) mmHg or diastolic blood pressure greater than ninety (90) mmHg.
Respirations- respiratory rate greater than thirty (30) breaths per minute or less than eight (8) breaths per minute.
A review of the facility policy, entity PPMH, "Triage Guidelines", last reviewed 08/24/16 revealed that the purpose of the policy was to provide a standardized system whereby patients presenting to the Emergency Center are treated in order of priority based upon acuity utilizing the Emergency Severity Index (ESI) Five-Level triage system. These guidelines are to standardize care and are not rules from which deviation may not occur or be appropriate.
Definitions in the policy included:
1. Triage: The process by which the initial management of patients was identified, and the priorities of care were assigned.
2. Immediate Bedding: The process by which a patient was sent to an open, available bed based on their clinical need.
3. Quick Registration: The process by which a patient's demographic information was entered into the hospital information system.
The policy was:
A. To provide a system to assist staff in expediting patient flow.
B. To ensure that all patients are seen in a timely and efficient manner based on the degree of acuity and resources required for the disposition of the presenting problem.
C. To provide a system for the reassessment of all patients that cannot be seen immediately in the Emergency Center (EC) for changes in their condition.
Further review of the policy revealed that all patients had an initial age-appropriate Triage assessment performed by a Registered Nurse (RN) to determine the acuity of the patient and to decide the appropriate treatment area for medical screening and/or treatment. All patients entering the EC were to have their complaint assessed by a Registered Nurse and categorized as Emergency Severity Index (ESI) Level 1, 2, 3, 4 or 5. The assigning of the ESI Level will be based on patient acuity and the number of resources required for disposition (admit/discharge/transfer). Patients whose condition interfered with vital physiological functions and required immediate medical attention were brought immediately to the treatment area. Patients who arrived by EMS ambulance were taken to the appropriate treatment area based on the initial triage.
Further review of the policy revealed the following exceptions to the policy:
Patients with a Behavioral Health Emergency
i. Patients that are clinically stable and required behavioral health/psychiatric evaluation were immediately placed in a quiet area, preferably the EC Behavioral Health area.
Patients who had been the victim of a Sexual Assault
ii. Alleged sexual assault victims were taken directly to a private exam room where age-appropriate assessments were completed by a nurse.
Patients who were pregnant
iii. All stable patients presenting to the EC with any problem of an obstetric nature and who are 20 weeks or more gestation was transported to Labor and Delivery for evaluation.
iv. If an OB patient 20 weeks or more presents to the EC with an Emergency problem and other signs and symptoms indicative of an acute illness or complaints associated with underlying medical conditions and/or trauma were to be stabilized in the EC and subsequently transferred to the Labor and Delivery for OB evaluation.
v. OB patients who are less than 20 weeks 'gestation were seen in the EC for any complaint. An OB consultation will be obtained as needed.

8. Staffing Schedules
A review of the staffing of the ED from 7/1/18 through 9/21/18 revealed that staffing was adequate and in following with facility policy. A review of provider schedules from 7/1/18 through 9/21/18 revealed adequate coverage.

9. Credentialing/Staff File Review.
A review of two (2) credential files (#5, and 9) revealed both files contained current state licensure and delineation of privileges. All files included evidence of current EMTALA training.
A review of seven (7) employee files (#1, 2, 3, 4, 6, 7 and 8) revealed all seven (7) files contained current state licensure and facility required orientation and competency testing. All seven (7) files contained evidence of current EMTALA training.

10. Facility Annual Compliance Training
A review of the facility's annual compliance training revealed that a review of EMTALA policies was performed.
A review of the ED department-specific annual competencies revealed that the topic of bedside monitors was included in the topics covered.

11. E-mail communications
Review of email communication dated 9/25/18 at 9:03 a.m. from Employee #1 to all Emergency Center staff revealed that staff members would not be allowed to work until they had reviewed and received information on the escalation guidelines. A member of the leadership would be present at shift huddles to present the information and have staff sign a roster. Attachments to the email included:
1. Alarm Monitor Processes revealed:
In addition to the current process, all alarm monitors were reminded of the escalation process for notification of nursing staff of patient alarms: -
· For 'yellow' alarms, the nurse had five (5) minutes to correct the alarm. The technician radioed the nurse every two (2) minutes until the alarm subsided and the nurse provided an acknowledgment that they had responded and checked on the patient.
· For 'red' alarms, the primary nurse was radioed immediately. The primary nurse was to acknowledge immediately and respond within sixty (60) seconds. If the primary nurse did not respond and the alarm did not subside within sixty (60) seconds, the charge nurse was radioed. If the charge nurse did not respond, the alarm technician should physically speak to someone to ensure that the patient is responded to.
· 'Red' alarms can no longer be silenced from the central monitoring station. 'Red' alarms can only be silenced at the patient's bedside by an RN.
2. 'RN Response to Alarm Notifications' revealed:
· The primary nurse must respond to and correct all 'yellow' alarms within five (5) minutes. Each time a nurse was notified on the radio, he/she must give acknowledgment.
· The primary nurse must respond to and assess all 'red' alarms within sixty (60) seconds. The primary nurse must acknowledge the alarm on the radio when received.
· If the primary nurse is unable to respond to the patient, it was the nurses' responsibility to escalate the call to the charge nurse or another nurse in the department. The primary nu