HospitalInspections.org

Review of the Nursing schedule for April 2012 through May 2012 revealed the following:
Emergency Department
2 RNs 7A-7P 7 days a week and a Ward Clerk 7A to 12A Monday through Friday and 7A through 11P Saturday and Sunday
Medical Unit
1 RN and 2 LPNs and 1 CNA 7 days a week

Review of the medical record for Patient #8 revealed she presented in the emergency room on 2/26/12 at 2230 (10:30 p.m.) with the complaint she needed to be quarantined because she was contagious from bug bites and stated bugs were crawling under her scalp. Further review revealed at 2/26/12 at 2315 the Emergency Room physician completed a PEC (Physicians Emergency Certificate) after determining Patient #8 was a threat to herself and was experiencing visual and tactile hallucinations. There was no documented evidence in the patient ' s chart one to one monitoring was performed by the nursing staff.

Review of the medical record for Patient #18 revealed she had been admitted to the emergency room on 1/22/12 at 1525 (3:25pm) with the chief complaint of attempted suicide and termination of her pregnancy by drinking bleach. Further review revealed at 1900 (7:00pm), a PEC (Physicians Emergency Certificate) was ordered by the emergency room physician. Review of the Nurses Notes for 1/22/12 and 1/23/12 revealed an unnamed CNA (certified nursing assistant) had been placed at the door of Patient #18's room to monitor her. Further review revealed no documented evidence patient #18 had been monitored on a constant basis by the nursing staff.

Patient #20
Review of the medical record for Patient #20 revealed a 15 year old female admitted to the Emergency Department on 12/17/11 at 1003 (10:03am) after claiming to have consumed three capfuls of bleach in an effort to kill herself because she was tired of being in foster care. Further review revealed #20 was PEC's (Physician's Emergency Certificate) on 12/17/11 at 10:30am for suicidal ideations with a past history of bipolar disorder, ADHD and borderline schizophrenia. Review of the Emergency Room Outpatient Record for Patient #20 dated/timed 12/17/11 10:40am (Late Entry) revealed 1:1 by CNA for observation. Further review revealed no documented evidence the name of the CNA (Certified Nursing Assistant) or any documentation patient #20 had been monitored constantly by the nursing staff.

Patient #21
Review of the medical record for Patient #21 revealed a 29 year old female admitted to the Emergency Department on 10/10/11 at 2310 (11:10pm) with complaints of stress over the past six months and not being able to take it anymore. Further she expressed "I thought about laying in the road". Further review of the medical record revealed she was PEC's on 10/10/11 at 2342 (11:42pm). Review of the Nursing Notes dated 10/10/11 2320 (11:20pm) through 10/11/11 at 0600 (6:00am) revealed no documented evidence Patient #21 was monitored by the nursing staff.

In a face to face interview on 5/24/12 at 11:00 a.m. RN S9 Nurse Educator indicated only LPNs (Licensed Practical Nurses) and RNs (Registered Nurses) were provided the CPI (Crisis Prevention Institute) Nonviolent Crisis Intervention Training. Further S9 verified the CNAs (Certified Nursing Assistants) and the contracted Security Guards had not been offered the training.

In a face to face interview on 05/24/12 at 2:00pm RN S6 ADON (Assistant Director of Nursing) indicated that when a patient was PEC ' d a nurse or CNA was pulled from the medical unit if the census allowed. The Security Guard was sometimes asked to assist with the PEC ' d patients as well. When asked for a list of the staffed pulled to the Emergency Department, S6 indicated the staff changes were not documented. Further S6 confirmed no documentation is performed by the staff monitoring the patient.

Based on record review (medical record, hospital policy, personal files) and interview the hospital failed to ensure the staffing and assignments of nurses were made in accordance to the needs of patients and the specialized qualifications/competence of staff by 1) assigning nursing assistants (CNAs) and contract security guards, who were not trained or certified in nonviolent de-escalation crisis intervention to the emergency room to assist with observation of the Physician Emergency Certified (PEC'd) patient for 4 of 4 (#8, #18, #20, #21) PEC'd patients out of a total sample of 21 emergency room medical records; 2) assigning registered nurses to administer and monitor vasoactive drips and assist with rapid sequence intubation in the emergency room setting without documented evidence of training and competency assessment for 2 of 3 (#9, #16) sampled patients with vasoactive drips and rapid sequence intubation out of a total sample of 21 emergency room medical records; and 3) assigning a nurse as charge in the Emergency Department after evaluating her as less than satisfactory and failing to implement corrective action (RN S4) to improve her skills. Findings:

1) assigning nursing assistants (CNAs) and contract security guards, who were not trained or certified in nonviolent de-escalation crisis intervention Patient #8 Review of the medical record for Patient #8 revealed she presented in the emergency room on 2/26/12 at 2230 (10:30 p.m.) with the complaint she need to be quarantined because she was contagious from bug bites and stated bugs are crawling under her scalp.
Review of the Physician Emergency Certificate revealed the patient was declared to be dangerous to self on 2/26/12 at 2315. History of present illness stated presented with complaints of bugs crawling out of skin. Excoriation, but no visible infestation, despite patient pointing out bugs that no one else sees. Under the section labeled mental condition revealed the patient was orientated x 3, anxious mood, pressured speech, flight of ideas, + (positive) visual and tactile hallucinations.
Review of the Nurses Notes revealed at 0010 (1:10 a.m.) the patient was placed in constant visual observation. At 1100 (11 a.m.) aroused without problem. Escorted in WC (wheelchair) to floor by CNA (name of staff member not documented) for shower. 1400 Amb (ambulate) out to smoke with staff nurse in attendance. Patient waiting for transfer to a psych facility. Patient was transferred to a psychiatric hospital on 2/27/12 at 1550 and was transported by the parish sheriff office.
Patient #18 Review of the medical record for Patient #18 revealed she had been admitted to the emergency room on 1/22/12 at 1525 (3:25 p.m.) with the chief complaint of attempted suicide and termination of her pregnancy by drinking bleach. Further review revealed at 1900 (7:00 p.m.), a PEC (Physicians Emergency Certificate) was ordered by the emergency room physician. Review of the Nurses Notes for 1/22/12 and 1/23/12 revealed an unnamed CNA (certified nursing assistant) had been placed at the door of Patient #18's room to monitor her. Review of the CNA personnel records at the hospital revealed none of the CNA's had been trained in monitoring a psychiatric patient.
Patient #20
Review of the medical record for Patient #20 revealed a 15 year old female admitted to the Emergency Department on 12/17/11 at 1003 (10:03am) after claiming to have consumed three capfuls of bleach in an effort to kill herself because she was tired of being in foster care. Further review revealed #20 was PEC's (Physician's Emergency Certificate) on 12/17/11 at 10:30am for suicidal ideations with a past history of bipolar disorder, ADHD and borderline schizophrenia.

Review of the Emergency Room Outpatient Record for Patient #20 dated/timed 12/17/11 10:40am (Late Entry) revealed 1:1 by CNA for observation. Further review revealed no documented evidence the name of the CNA (Certified Nursing Assistant). Review of all personnel files of the Certified Nursing Assistants employed by the hospital revealed none had been trained to care for or monitor a psychiatric patient.

Patient #21
Review of the medical record for Patient #21 revealed a 29 year old female admitted to the Emergency Department on 10/10/11 at 2310 (11:10pm) with complaints of stress over the past six months and not being able to take it anymore. Further she expressed "I thought about laying in the road". Further review of the medical record revealed she was PEC's on 10/10/11 at 2342 (11:42pm).

Review of the Nursing Notes dated 10/10/11 2320 (11:20pm) through 10/11/11 at 0600 (6:00am) revealed no documented evidence Patient #21 was monitored for behavior by the nursing staff.

In a face to face interview on 5/24/12 at 11:00 a.m. RN S9 Nurse Educator indicated only LPNs (Licensed Practical Nurses) and RNs (Registered Nurses) were provided the CPI(Crisis Prevention Institute) Nonviolent Crisis Intervention Training. Further S9 verified the CNAs (Certified Nursing Assistants) and the contracted Security Guards had not been offered the training. .
Review of the sign in sheets for CPI Non-violent Crisis Intervention Training for 9/7/11, 9/12/11, 9/13/11, 9/14/11 revealed only LPNs (licensed practical nurses) and RNs (registered nurses) attended the Non-violent Crisis Intervention Training Program.
An interview was conducted with S3 Assistant Director of Nurses (ADON) on 5/24/12 at 8:30 a.m. She reported that the contract security guards are used if a patient gets out of hand in the Emergency Room (ER) Department. The ER nurses have been instructed to call security if they need assistance. S3 also stated CNAs as well as the security guards are used to perform the observation on the PECed (Physician Emergency Certificate) patients in the ER. S3 confirmed on the CPI Non-violent Crisis Intervention Training sign in sheets none of the hospital's CNAs had attended the classes.
An interview was conducted with S8 Security Guard on 5/24/12 at 1 p.m. He reported he worked for Company "B", the contract security agency the hospital hired for security. He went on to report he worked 6 p.m. to 6 a.m./ 42 hours a week at the hospital. S8 stated for the PEC patients, he usually helps with observing the patients for the nurses. He sits by the door to make sure the patient does not hurt his or herself or attempt to run away from the hospital. When questioned if Company "B" had ever provided formal training on nonviolent de-escalation crisis intervention, he stated they had not.
Review of the training information on S8 Security guard provided by Company "B" revealed no nonviolent de-escalation crisis intervention training.

2) assigning registered nurses to administer and monitor vasoactive infusions and assist with rapid sequence intubation
Patient #9
Review of the medical record for Patient #9 revealed a 52 year old female admitted to the Emergency Department on 02/13/12 at 0315 (3:15am) in respiratory distress. Further review revealed Patient #10 had a history of COPD (Chronic Obstructive Pulmonary Disease) and was recently seen in ED with similar symptoms.

Review of the Emergency Room Nursing Triage and Assessment form for Patient #9 revealed a blood pressure of 203/103 and a Tridil drip was initiated at 0340 (3:40am) at a rate of 10mcg/hr IV (intravenous) per pump by RN S14. Further review revealed the following: 0414 (4:14am) MD at bedside for intubation, Versed 5mg IVP (intravenous push) given; 04/15 (4:15am) Diprivan 50mg IVP given per MD; 0418 (4:18am) Intubation attempt unsuccessful. Bagging pt. (patient); 0419 (4:19am) Roncurium 50mg IVP given per MD; 0420 (4:20am) Pt. intubated.

Review of the Competency Testing Checklist dated 10/11 for RN S14 revealed no documented evidence that competency in administration of Tridil infusions, or any other vasoactive intravenous infusion was assessed. There was no documented evidence of a competency assessment of assistance with rapid sequence intubation (Expeditious induction of general anesthesia and subsequent intubation of the trachea).


Patient #16
Review of the patient's emergency room record revealed the patient was transferred by ambulance from a rehabilitation hospital to the emergency room on 04/30/12 at 0050 (12:50 a.m.).

The Emergency Room Nursing Triage & Assessment form revealed the following:
Date: 04/30/12
Triage Time: 0050 (12:50 a.m.)
Triage Vital Signs: Temperature: 96.7, Pulse: 59, Respiration: 32, Blood Pressure: 139/60, Oxygen Saturation: 75%
Chief Complaint: to ER 5 per ambulance stretcher - nurse from rehab hospital states patient SOB (Short of Breath) X 2 days unable to get O2 (Oxygen) Sat (Saturation) above 88 today - on CPAP (Continuous Positive Airway Pressure). Has PICC (Peripherally Inserted Central Catheter) line in left upper arm - PEG (Percutaneous Endoscopic Gastrostomy) tube, Foley Catheter to GU (Genito-urinary) bag - 50 cc (cubic centimeters) clear urine in bag.

Review of the Code Blue Record revealed the Time Begun was 0127 (1:27 a.m.) and the Time Ended was 0156 (1:56 a.m.).
Review of the medications administered revealed that Rocuronium (Neuromuscular Blocker used for endotracheal intubation) 5 cc was administered at 1:24 a.m. and 2 cc was administered at 1:26 a.m.
Review of the medications administered revealed that a Dopamine infusion was started at 1:49 a.m. at 5 mcg. by S11RN

Review of the personnel record for S11RN revealed a Competency Testing Checklist form signed by 3 different RNs including S3RN. There was no documented evidence of a date on the checklist. There was no documented evidence that competency in administration of Dopamine infusions, or any other vasoactive intravenous infusion was assessed. There was no documented evidence of a competency assessment of assistance with rapid sequence intubation (Expeditious induction of general anesthesia and subsequent intubation of the trachea).

Review of the Emergency Room Protocols submitted by RN S6 Assistant Director of Nursing (ADON) as the ones currently administered in the hospital revealed the following: Cardizem, Cerebyx, Cordarone, Phenytoin, Diprivan, Dopamine, Eptifibatide, Natrecor, Magnesium Sulfate, Nitroglycerin, Nipride, Pavulon, and Rocurium.

On 05/24/12 at 12:40 p.m. a face to face interview was conducted with S3RN, Assistant Director of Nursing. After reviewing the personnel record for S11RN, S3 confirmed there was no documented evidence of any competency assessment for the use of Dopamine or any other vasoactive infusion used in the emergency department. S3RN confirmed there was no competency assessment for assisting with rapid sequence intubation in the emergency department. S3RN confirmed S11RN had performed the Dopamine infusion and assisted with a rapid sequence intubation on 04/30/12 for Patient #16.

3) assigning a nurse as charge in the Emergency Department after evaluating her as less than satisfactory and failing to implement corrective action (RN S4) to improve her skills
Record review revealed a Job Performance Review dated 11-7-11 for Registered Nurse (RN) S4. The review was performed by Director of Nursing (DON) S2. The document listed in part:
...6. Channels to the Director of Nursing the pertinent information concerning patient care, performance of personnel and other activities on the nursing units and from other departments or physicians affecting nursing. Comments (By DON S2): "Usually not in a timely manner. You do so when it's convenient for you." Performance rated as "needs improvement" ... ...14. Understands and sets example during emergency procedures, fire drills, evacuations, internal disaster plans and procedures. Comments (By DON S2): "Questionable decision making in critical situations." Performance was rated as "needs improvement" ... ...16. Demonstrates knowledge by identifying patient needs and selecting the best nursing action. Comments (By DON S2): "Questionable critical thinking skills." Performance was rated as "needs improvement" ... ...36. Communicates therapeutically with patients and recognizes their physical, emotional and sociological needs. Comments (By DON S2): "Confrontational approach with patient/family at times" Performance was rated as "needs improvement" ... ...38. Makes decisions in those matters for which he has responsibility. Comments (By DON S2): " Responsibility lies in making decisions as a leader and as being in charge-some decisions are questionable. "Performance was rated as "needs improvement" ....Areas for Improvement (By DON S2): "Even though you have all these years of experience you have not progressed to lead and take charge and to be able to effectively take care of critical procedures and critical situations". Goal for Next Year (By DON S2): "Make sure that you know how to perform any critical procedure that needs to be done to save someone's life and that you know how to direct others in doing so also". Steps for Accomplishing Goal or Resolving Problems (By DON S2): ... "Step up to the plate and be a strong RN (Registered Nurse) and not depend on others as you have done for years". Further review revealed Registered Nurse S6's performance was rated in 38 areas. 17 areas were scored by DON S2 as being average, 13 areas were scored as needing improvement, and 3 areas were scored as unsatisfactory.
An interview was held with Assistant Director of Nursing (ADON) S3 on 5/24/12 at 8:35 a.m. She said RN S6 was a follower instead of a leader. S3 also said S6 ' s judgment could be improved. S3 stated after the person that used to work with S6 at night had moved to the day shift, she realized S6 had been " carried " by the stronger nurse. She further said she had seen problems by S6 that had not been taken care of in a timely manner. She also said RN S6 was routinely scheduled as the charge nurse of the emergency room and the inpatient unit.

An interview was held on 5/24/12 at 8:50 a.m. with DON S2. She said with the exception of the last couple of months, when the ADON began helping her, she had been responsible for completing performance evaluations on the nursing staff since 1980. She said S6 had many bad performance evaluations because she was a weak Registered Nurse who had been "carried" by a strong RN that made all of the nursing decisions when needed. She stated S6 worked as the charge nurse of the emergency room and inpatient unit repeatedly although her critical thinking skills were not good. When asked why she had been assigned as charge nurse repeatedly although she thought she had poor critical thinking skills, she replied, "Sometimes your hands are tied because if you get rid of her, maybe somebody worse will be hired".

Review of the nursing schedules dated 3/8/12 through 5/29/12 revealed RN S6 had been in charge of the Inpatient unit 7 times and the Emergency Room 20 times.




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Based on record review (medical record, hospital policy) and interview the hospital failed to ensure a Registered Nurse supervised the nursing care for each patient by: 1) failing to ensure assessments were performed on patients after administration of pain medication and respiratory treatments for 6 of 21 emergency room records reviewed (#2, #4, #6, #7, #9, #10); 2) failing to ensure vital signs were re-assessed in the emergency room more frequently than at triage and discharge for 3 of 21 sampled emergency department medical records reviewed (#2, #8, #20); and 3) failing to ensure patient were triaged and assessed by a Registered Nurse for 1 (#17) of 21 sampled patients. Findings:

1) failing to ensure assessments were performed on patients after administration of pain medication and respiratory treatments
Patient #2 Review of Patient #2's Emergency Room Nursing Triage and Assessment dated 1/15/12 and timed 0148 (1:48 a.m.) revealed she was a 32 year old female with the complaint of pain to her left knee.
Review of the Nurses Notes revealed at 0210 (2:10 a.m.) Toradol 60 mg (milligrams) was given IM (intramuscularly) in her left hip. There was no documentation of the patient's response to the pain medication or a pain assessment after administration of the pain medicine.
Review of the Nurses Notes revealed at 0320 (3:20 a.m.) Demerol 25 mg and Phenergan 12.5 mg IVP (intravenously) was administered to the patient. There was no documentation related to the response to the medication and a pain assessment prior or after administration of the medication.
An interview was conducted with S3ADON at 5/24/12 at 9:15 a.m. She stated she would expect the emergency room nurses to do an assessment after pain medications were administered.
Patient #4
Review of the medical record for Patient #4 revealed a 50 year old male admitted to the Emergency Department on 01/16/12 at 2250 (10:50pm) with complaints of shortness of breath and back pain after a fall. Review of the Physician Record (physician exam and physician orders) revealed an order for Solumedrol 125mg IV (intravenous), and an Xopenex/Albuterol treatment.

Review of the Emergency Room Nursing Triage and Assessment form for Patient #4 dated 01/16/12 revealed 2357 (11:57pm) Solumedrol 125mg IV given, Xopenex/Albuterol treatment.
in progress. Further review of the medical records revealed no documented evidence the effects of the medication administered or the treatment performed had been assessed.

Patient #6
Review of the patient's emergency room record revealed the patient arrived by ambulance to the emergency room at 0449 (4:49 a.m.) on 04/05/12. Review of the Chief Complaint revealed the patient presented on a stretcher on a spine board with a cervical collar in place after being involved in a motor vehicle accident.

Review of the nursing documentation revealed that Toradol 30 mg. IVP (Intravenous push) was administered at 0650 (6:50 a.m.). Toradol is a non-steroidal anti-inflammatory medication used for pain. There was no documented evidence of where the patient's pain was located or how intense the pain was. There was no documented evidence of the patient's response to the medication.

Review of the nursing documentation revealed that Dilaudid 0.5 mg. IVP was administered at 0800 (8:00 a.m.). Dilaudid (Hydromorphone) is a schedule II pain medication. There was no documented evidence of the location or intensity of the patient's pain. There was no documented evidence of the patient's response to the pain medication.

Review of the nursing documentation revealed that Phenergan 12.5 mg IVP was administered at 0835 (8:35 a.m.) and Dilaudid 0.5 mg IVP was administered at 0840 (8:40 a.m.). Further review of the nurse's documentation revealed the following: "0941 (9:41 a.m.) - Late entry 0900 (9:00 a.m.) patient rates pain 5/10." There was no documented evidence of the location of the patient's pain and there was no documented assessment of the intensity of the pain prior to the pain medication.

Review of the nurse's documentation revealed the following: "1030 (10:30 a.m.) Patient complained of pain rate 8/10; Dilaudid 0.5 mg. IVP given per order." There was no documented evidence of the location of the patient's pain. At 10:50 a.m., the nurse documented the patient's pain was 5/10, but there was no documented evidence of the location of the pain. Review of the nursing documentation revealed no other documentation regarding pain or pain medication. The record revealed the patient was transferred to another facility at 12:00 p.m.

On 05/24/12 at 10:40 a.m., a face to face interview was conducted with S3RN, Assistant Director of Nursing. After reviewing the emergency room record for Patient #6, she confirmed there was no documented evidence of where the patient's pain was located, and there was no assessment of the intensity of the pain until after the pain medication was administered. S3RN confirmed the above documentation of pain medications administered to Patient #6.

Patient #7
Review of the medical record for Patient #7 revealed a 27 year old male admitted to the Emergency Department on 02/16/12 at 0201 (2:01am) with a complaint of chest wall pain.
Review of the Physician Record (no date/time the documented) revealed an order for Toradol 60mg IM (Intramuscular).

Review of the Emergency Room Nursing Triage and Assessment form for Patient #7 dated
02/16/12 revealed 0320 (3:20am) Toradol 60mg IM to R (right) hip and removed HL (Hep Lock). 0350 (3:50am) Pt. (patient) discharged to lobby to wait for ride. Further review of the medical records revealed no documented evidence the effects of the medication administered.

Patient #9
Review of the medical record for Patient #9 revealed a 61 year old female admitted to the emergency room on 02/13/12 for respiratory distress with a pulse of 144, blood pressure of 202/103 and respirations of 35. Further review revealed Patient #9 had a Xopenex treatment in progress. Review of the Physician Record (no date/time the documented) revealed an order for
Lasix 40mg IVP, 2nd Xopenex treatment, Duoneb treatment, and epinephrine 0.3mg.

Review of the Emergency Room Nursing Triage and Assessment form for Patient #7 dated 02/13/12 revealed no documented evidence the lung fields were re-assessed after medication and treatments were administered.

Patient #10
Review of the medical record for Patient #10 revealed a 55 year old female admitted to the emergency department on 02/04/12 at 0440 (4:40am) with asthma, coughing, and wheezing. Review of the Physician Record (physician exam and physician orders) revealed orders for a Duoneb Treatment and Decadron 8mg IM X (times) 1 now.

Review of the Emergency Room Nursing Triage and Assessment form for Patient #10 dated 02/04/12 revealed no documented evidence the lung fields were re-assessed after medication and treatments were administered or the absence of any adverse drug reaction.


2) failing to ensure vital signs were re-assessed in the emergency room more frequently than at triage and discharge Patient #2 Review of Patient #2's Emergency Room Nursing Triage and Assessment dated 1/15/12 and timed 0148 (1:48 a.m.) revealed she was a 32 year old female with the complaint of pain to her left knee.
Review of the Nurses Notes revealed a set of vital signs were obtained on Patient #2 at triage on 1/15/12 at 0148 (1:48 a.m.) and on discharge at 0355 (3:55 a.m.).
Review of the Nurses Notes revealed at 0210 (2:10 a.m.) Toradol 60 mg (milligrams) was given IM (intramuscularly) in her left hip. There was no documentation of the patient's response to the pain medication or a pain assessment after administration of the pain medicine.
Review of the Nurses Notes revealed at 0320 (3:20 a.m.) Demerol 25 mg and Phenergan 12.5 mg IVP (intravenously) was administered to the patient. There was no documentation related to the response to the medication and a pain assessment prior or after administration of the medication.
An interview was conducted with S3ADON at 5/24/12 at 9:15 a.m. She stated she would expect the emergency room nurses to do vital signs more frequently since pain medication was administered.
Patient #8 Patient #8 presented in the emergency room on 2/26/12 at 2230 (10:30 p.m.) with the complaint she need to be quarantined because she was contagious from bug bites and she stated bugs are crawling under her scalp.
Review of the Physician Emergency Certificate revealed the patient was declared to be dangerous to self on 2/26/12 at 2315. The history of present illness stated she presented with complaints of bugs crawling out of skin. Excoriation, but no visible infestation, despite patient pointing out bugs that no one else sees. Under the section labeled mental condition revealed the patient was orientated x 3, anxious mood, pressured speech, flight of ideas, + (positive) visual and tactile hallucinations.
Review of the nurses notes revealed at 0000 (12:00 a.m.) Patient #8 was given Haldol 5 mg (milligrams) IV (intravenous) and Valium 10 mg IV given. Geodon 40 mg po (by mouth) was documented as given at 1250 (12:50 p.m.) on 2/27/12. Vital signs were documented on triage on 2/26/12 at 2230 (10:30 p.m.), 2/27/12 at 0800 (8 a.m.), 2/27/12 at 1400 (2 p.m.) and on transfer to the psychiatric hospital on 2/27/12 at 1610 (4:10 p.m.) The patient was in the emergency room for 19 ? hours and the patient's vital signs were only documented 4 times.
An interview was conducted with S3ADON on 5/24/12 at 9:15 a.m. She stated she would expect the patients vital signs to be taken every couple of hours especially if medications are administered.
Patient #20
Review of the medical record for Patient #20 revealed a 15 year old female admitted to the Emergency Department on 12/17/11 at 1003 (10:03am) with complaints of wanting to kill herself because she was tired of being in foster care and drank three capfuls of bleach.

Review of the Emergency Room Nursing Triage and Assessment form for Patient #20 dated
12/17/11 revealed vital signs were assessed at the time of triage 10:03am as temperature - 98.5 degrees Fahrenheit, Pulse - 94, Blood Pressure 110/77 and Oxygen Saturation 100%. Further review revealed no documented evidence vital signs were evaluated again until discharge at 1355 (1:55pm).
The hospital could not submit a policy for assessment of vital signs in the Emergency Department.

In a face to face interview on 05/24/12 at 9::15am RN S6 ADON (Assistant Director of Nursing) indicated she would expect a patient in the Emergency Room to have his/her vital signs assessed at least every two hours. Further, in the Emergency Department assessments should be performed after drug administration the length of time after depends on the drugs given.



3) failing to ensure patient were triaged and assessed by a Registered Nurse
Patient #17
Review of the patient's Emergency Room Nursing Triage & Assessment form revealed the patient arrived at the emergency room on 01/09/12 at 2357 (11:57 p.m.) with a chief complaint documented as chest pain during breathing and very weak for about one hour. Review of the form revealed the triage was completed by S15LPN. Review of the checklist assessment revealed the entire section was blank. There was no documented evidence of any nursing assessment done for Patient #17.

On 05/23/12 at 10:30 a.m., S3RN, ADON was interviewed and stated she was not aware that LPNs were not allowed to triage until she attended a training a couple of weeks ago. S3RN verified LPNs had triaged patients in the emergency room until recently.

On 05/24/12 at 10:25 a.m., a face to face interview was conducted with S3RN, ADON. After reviewing the emergency room record for Patient #17, she confirmed there was no nursing assessment documented on Patient #17. S3RN confirmed that S15LPN had triaged the patient and stated that LPNs were not allowed to triage and triage was the responsibility of the registered nurse.

Based on record review and interview the hospital failed to ensure the emergency room physician dated/ timed the physical examinations and orders for 16 (#1,#2, #3, #4, #7, #8, #9, #10, #11, #13, #15, #17, #18, #19, #20, #21) of 21 sampled patients. Findings:

Patient #1
Review of the medical record for Patient #1 revealed he had been admitted on 1/19/12 at 2331 (11:31 p.m.) with the chief complaint of being thrown from a horse.
Review of the "Emergency Department Physician Record" for Patient #1 revealed the physician had not timed or dated his assessment or orders.

Patient #2
Review of the medical record for Patient #2 revealed she was seen in the emergency room on 1/15/12 and triaged at 0148 (1:48 a.m.) for left knee pain.

Review of the Physician Record (physician exam and physician orders) revealed no date or time the exam was performed and no date and time the orders were written.

An interview was conducted with S3ADON at 9:15 a.m. She confirmed the Physician Record was not dated and timed by the physician.

Patient #3
Review of the patient's emergency room record revealed the patient was a 3 year old female that arrived at the emergency room on 01/19/12 at 0223 (2:23 a.m.) with a chief complaint documented as shortness of breath, trouble breathing since last night. Review of the Emergency Department Physician Record revealed there was no documented evidence of the time the medical screening was done. Further review of the physician record revealed the following orders: CXR (Chest x-ray), Saline lock, CBC, CMP, UA, , Zofran 4 mg. IV X1 (Nausea Medication given by intravenous injection), RL (Ringer's Lactate) 1000 ml at 200 ml/ bolus then recheck temperature and pulse. Xopenex aerosol, Prednisone 15 mg/5 ml - 10 ml PO (By mouth) (30 mg.), Rocephin 500 mg IV (Antibiotic given by intravenous infusion), repeat aerosol, Motrin suspension 3/4 teaspoon PO. There was no documented evidence of any time on any of the orders. There was no date documented by the physician on the physician record.

On 05/24/12 at 10:20 a.m., a face to face interview was conducted with S3RN, Assistant Director of Nursing (ADON). After reviewing the above records, she confirmed there was no documented evidence of the time the medical screening exam was done and there was no documented evidence of the time the physician wrote the orders. S3RN stated they had implemented a new form to help in getting the physicians to date and time the orders. S3RN and confirmed the form was titled Department Record Physician Order Sheet. After reviewing the record for Patient #3, S3 confirmed the new form was used by the physician, but the physician had failed to document a time for the initial orders.

Patient #4
Review of the medical record for Patient #4 revealed a 50 year old male admitted to the Emergency Department on 01/16/12 at 2250 (10:50pm) with complaints of shortness of breath and back pain after a fall. He was assessed as an Acuity Level II.

Review of the Physician Record (physician exam and physician orders) revealed no date or time of the exam was performed or the orders for the CMP, Urinalysis, Solumedrol 125mg IM (intramuscular), Chest x-ray, Tramadol 50mg ii tablets po (by mouth) now, oxygen 2 liters, and Xopenex treatment were written.

Patient #7
Review of the medical record for Patient #7 revealed a 27 year old male admitted to the Emergency Department on 02/16/12 at 0201 (2:01am) with a complaint of chest wall pain. He was assessed as an Acuity Level III.

Review of the Physician Record (physician exam and physician orders) revealed no date or time the exam was performed or orders for a CBC, CMP, Cardiac, Alcohol, I&O (In & Out) catheter, chest x-ray, and EKG were written.

Patient #8
Review of the medical record for Patient #8 revealed the patient was seen in the emergency room on 2/26/12 and triage time was documented at 2230 (10:30 a.m.). She had come to the emergency room with the complaint for the need to be "quarantined" because she had bugs crawling under her scalp.

Review of the Physician Record (physician exam and physician orders) revealed no date or time of the exam or orders.

An interview was conducted with S3 ADON on 5/24/12 at 9:15 a.m. She confirmed the physician did not date or time his exam or orders.

Patient #9
Review of the medical record for Patient #9 revealed a 52 year old female admitted to the Emergency Department on 02/13/12 at 0315 (3:15am) in respiratory distress. She was assessed as an Acuity Level I.

Review of the Physician Record (physician exam and physician orders) revealed no date or time the exam was performed or orders for a CBC, Cardiac, CMP, EKG, Chest x-ray, Lasix 40mg IVP (intravenous push), Hep lock and Tridil were written.

Patient #10
Review of the medical record for Patient #10 revealed a 55 year old female admitted to the emergency department with asthma, coughing, and wheezing. She was assessed as an Acuity Level II.

Review of the Physician Record (physician exam and physician orders) revealed no date or time the exam was performed or orders for a Duoneb Treatment, Rapid Strep and Rapid Flu and Decadron 8mg IM X (times) 1 now were written.

Patient #11
Review of the patient's emergency room record revealed the patient arrived by ambulance to the emergency department on 04/05/12 at 0445 (4:45 a.m.). The patient's chief complaint was documented as MVA (Motor Vehicle Accident) complaint of neck pain, ambulatory at scene. Review of the Department Record Physician Order Sheet revealed the following initial orders: CBC with diff (Complete Blood Count with differential), CMP (Comprehensive Metabolic Profile), UPT (Urine Pregnancy Test), UA (Urinalysis), UDS (Urine Drug Screen), ETOH (Alcohol level), Thoracic spine X-ray. There was no documented evidence of the time of the initial orders.

Patient #13
Review of the medical record for Patient #13 revealed he had been triaged on 4/5/12 at 0455 (4:55 a.m.). His chief complaint was back pain resulting from a motor vehicle accident.

Review of the "Physician Order Sheet" for Patient #13 from the emergency room revealed orders for labs, CT scans (computerized tomography), and medications were not timed or dated.

Patient #15
Review of the medical record for Patient #15 revealed she was 3 year female with generalized seizures at home that had been brought to the emergency room by an ambulance. Documentation revealed she had been triaged by the nurse on 5/19/12 at 0531 (5:31 a.m.).

Review of the physician's exam revealed no date or time the patient was examined.

Patient #17
Review of the patient's emergency room record revealed the patient arrived at the emergency room on 01/09/12 at 2357 (11:57 p.m.) with a chief complaint documented as chest pain during breathing and very weak for about one hour. Review of the Emergency Department Physician Record revealed there was no documented evidence of the time the medical screening was done. Further review of the physician record revealed the following orders: CBC, CMP, UA, UDS, Blood Cultures X2, Zofran 8 mg. IV X1 (Nausea Medication given by intravenous injection), Toradol 30 mg. IV X1 (Pain Medication given by intravenous injection), and CT (Computerized Tomography) Chest without (Scan of chest without using contrast media). There was no documented evidence of any time on any of the orders. There was no date documented by the physician on the physician record.

Patient #18
Review of the medical record for Patient #18 revealed she had been admitted to the emergency room on 1/22/12 at 1525 (3:25 p.m.) with a chief complaint of attempted suicide and termination of her pregnancy by drinking bleach.
Review of the "Emergency Department Physician Record" for Patient #18 revealed the physician had not timed or dated his orders or physical exam.

Patient #19
Review of the medical record for Patient #19 revealed the patient was seen in the emergency room on 2/9/12 and triaged at 1015 (10:15 a.m.). She had received dialysis and became lethargic after the dialysis was completed.

Review of the Physician Record (physician exam and physician orders) revealed no date or time the exam was performed and no date or times the orders were written.

Patient #20
Review of the medical record for Patient #20 revealed a 15 year old female admitted to the Emergency Department on 12/17/11 at 1003 (10:03am) with complaints of wanting to kill herself because she is tired of being in foster care and drank three capfuls of bleach. She was assessed as an Acuity Level II.

Review of the Physician Record (physician exam and physician orders) revealed no date or time the exam was performed or orders for a CBC, CMP, Urinalysis, and UPT were written.

Patient #21
Review of the medical record for Patient #21 revealed a 29 year old female admitted to the Emergency Department on 10/10/11 at 2310 (11:10pm) with complaints of stress over the past six months and not being able to take it anymore. Further she expressed "I thought about laying in the road". She was assessed as an Acuity Level II.

Review of the Physician Record (physician exam and physician orders) revealed no date or time the exam was performed or orders for a CBC, CMP, Urinalysis, Tylenol Level, Chest x-ray, Ativan 2mg IM (intramuscular) X1 and Haldol 5mg IV (intravenous) X1 were written.



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Based on record review and interview the hospital failed to ensure the Emergency Department implemented and maintained a quality assurance program which evaluated the care provided as evidenced by identified problems in the care of psychiatric patients, patients with severe respiratory problems and patients on vasoactive drips and distraction of paralytic agents for rapid sequence intubations were monitored. Findings:

Review of the Emergency Room Quality Assurance Plan developed in 1992 and submitted as the one currently in use revealed..... "Objectives: D. Identify problems, potential problems, systems, or processes that involve the patients' health and safety".

Review of the data collected in the Emergency Department included the following: total number of patient visits, total number of admits, transfers, AMAs (leaving against medical advise), LWBS (leaving without being seen), desertions, unscheduled returns, deaths, codes, DNRs (Do Not Resuscitate), DOAs (Dead on Arrival), Restraints and PEC's (Physician's Emergency Certificate).

Review of the Monthly QI Report of the Emergency Department dated 01/2012 revealed no documented evidence care of the psychiatric patient, appropriateness of the care provided during a code, administration/monitoring,of vasoactive drugs, and availability of respiratory services in respiratory emergencies, accuracy of triage assessments were evaluated as part of the QA process.

In a face to face interview on 05/22/12 at 8:00am RN S4 Emergency Room nurse indicated identified problems in the ED (Emergency Department) included lack of clerical help after hours making it necessary for 1 of the 2 nurses assigned to the ED to perform registration and triage as well as patient care. In addition, respiratory is not always available after hours during codes and intubations needing a ventilator set-up. S4 indicated the Emergency Room is continuing to see increasing numbers of psychiatric patients who are in need of constant observation.

In a face to face interview on 05/24/12 S15 QA Director indicated the Director of Nursing was responsible for the data collection in the Emergency Department. Further S15 indicated he was aware that not all of the departments were participating in improvement projects; however he only had the authority to remind the department heads this needed to be done.

In a face to face interview on 05/24/12 at 1:25pm RN S2 Director of Nursing indicated she does perform chart reviews in the emergency department. When asked about the reason for the high numbers of AMA, LWBS and desertions S2 was not able to give an answer. Further S2 indicated she reviewed all codes and found no problems, including availability of the respiratory department. While S2 agreed that the volume of PEC'd patients were increasing, no analysis of the data had been performed.