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Based on review of documentation and interview with staff, it was determined the nursing staff failed to supervise and evaluate care on 3 of 10 medical records reviewed for patients who presented to the ED with cardiac symtoms. The nursing staff also failed to acknowledge physician orders in 8 of 10 patient medical records.

Findings included:

Review of facility policy entitled, "Patient Rights and Responsibilities" stated, "I. Patient Rights, The District has adopted the following statements of patient rights ...Considerate, dignified and respectful care, provided in a safe environment, free from all forms of abuse, neglect ..."

Review of facility policy entitled, "Nursing Documentation" stated "It is the policy of Department of Emergency Medicine (DEM) to provide specific guidelines for consistent documentation of nursing care. Further review revealed, "E. Nursing documentation will include: Documentation of other parameters such as ... Continuous Cardiac Monitoring ... F. Patient observations should be performed and documented as indicated by the patient's clinical status."

1. The medical record of patient #10 revealed the patient presented to the ED on 12/14/2011 at 11:26am and had an abnormal EKG. The patient was transferred to bed in the Emergency Department (ED) at 11:36am. Documentation revealed the patient was not placed on a cardiac monitor until 11:58am when he was transferred to a room. The patient had a history of a heart attack and atrial fibrillation. The patient presented to ED with chest pain and was not monitored for a 22 minute time period which could have placed the patient's safety in jeopardy.

2. The medical record of patient #4 revealed the patient presented to the ED on 12/29/2011 at 12:46am with swelling to the penis and lower legs for 3 days and had a history of atrial fibrillation. The EKG performed at 2:34am stated atrial fibrillation. Patient #4 was first transferred to an area in the ED without a cardiac monitor. Physician #6 at 4:07am documented the patient was in need of a monitored bed. Patient #4 was then transferred to an area from the ED waiting room that does not have cardiac monitors in the rooms. There was no documentation in the medical record the patient was on a cardiac monitor until 5:21am when the patient was transferred to another area in ED that had monitors in the room. The patient presented to ED with chest pain and was not monitored for a 4 hour and 15 minute time period which could have placed the patient's safety in jeopardy.

3. The medical record of patient #5 revealed the patient present to the ED with chest pain and shortness of breath on 12/28/2011 at 11:28pm and the patient left without being seen. Documentation revealed the nurse called the patient 13 minutes later and the patient did not answer. The patient presented to the ED with chest pain and there was no documentation the patient was triaged.

4. Review of 8 of 10 (#1, 2, 4, 6, 7, 8, 9, 10) medical records, the nurse failed to acknowledge physician orders. The nurse failed to sign, date, and time the order sheet as the signature line was blank.

The above was confirmed in multiple interviews on 6/ 20/2012 with staff member #1 and #2. Staff member #14 stated in an interview on 6/20/2012 at 10:40am that nurse's must sign, date, and time all physician orders and that the issue had been discussed with them.

Based on review of documentation and interview with staff, it was determined the facility failed to adequately staff shifts to meet the patient needs.

Findings included:
Staff member #2 stated in an interview on 6/19/2012 at 12:30pm the ED staff's 16 RN's per shift and in the projected new budget for 10/2012 they are increasing staffing to 20-23 RN's.

Review of Emergency Department (ED) staffing schedules revealed:

1. On 12/14/2011 shift 7:00pm-7:00am, there was the team leader absent and the staffing schedule did not have the name of the needed staff members to fill the positions needed. Also on 12/14/2011, in the yellow area which was critical care, there was 1 nurse scheduled to work in the critical care area during this shift. There was no clerk available in the yellow area. There was no documentation the facility filled the needed positions. These staffing issues were a potential for placing patient safety at risk.

2. On 12/28/2011 shift 7:00pm -7:00am there was 1 nurse absent, one nurse was working 7:00pm-12:00am, one tech was absent, there was no tech scheduled in the purple area which was the fast track, and there was no EKG tech scheduled. Documentation also revealed there were 14.8 Registered Nurse's (RN) and zero Licensed Vocational Nurse's (LVN) scheduled to work on this shift for the ED. There was no documentation the facility filled the needed positions. These staffing issues were a potential for placing patient safety at risk.

3. On 12/29/2011 shift 7:00am-7:00pm, there was the flow facilitator and a nurse absent. Also, the intake nurse was late. Documentation also revealed there were 13.8 Registered Nurse's (RN) and zero Licensed Vocational Nurse's (LVN) scheduled to work on this shift for the ED. There was no documentation the facility filled the needed positions. These staffing issues were a potential for placing patient safety at risk.

4. On 12/29/2011 shift 7:00pm-7:00am, the yellow area which was the critical care area did not have a tech. Documentation revealed there were 14.8 Registered Nurse's (RN) and zero Licensed Vocational Nurse's (LVN) scheduled to work on this shift for the ED. There was no documentation the facility filled the needed positions. These staffing issues were a potential for placing patient safety at risk.

5. On 12/30/11 shift 7:00pm-7:00am revealed there were 10.9 Registered Nurse's (RN) and one Licensed Vocational Nurse's (LVN) scheduled to work on this shift. There was no documentation the facility filled the needed positions. These staffing issues were a potential for placing patient safety at risk.

The above was confirmed in multiple interviews on 6/19-20/2012 with staff members #1 and #2.