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Based on observation, staff interview and document review, it was determined the facility failed to inform each patient, or when appropriate, the patient's representative as allowed by law, of the patient's rights for twenty one of twenty two patients in the survey sample (Patients # 1 - #7 and #9 - #22) and failed to follow the facility policy for transfer for one (1) of one (1) patient requesting transfer (Patient # 2).

The findings include:

Medical records were reviewed on August 29, 2017 and August 30, 2017 and revealed no evidence that notification of Patient Rights were being given to the patients or the patient's representative for Patients # 1 - #7 and #9 - #22).

Staff Members (SM) #26, a registered nurse was interviewed on the Progressive Care Unit on August 30, 2017 at approximately 3:20 P.M. He/she stated the nursing staff do not inform patients of the patient rights.

SM #27, Bed Center Coordinator, was interviewed on August 30, 2017 at approximately 3:35 P.M. SM #27 revealed that admitting registrars do not inform the patients of their patient rights. Staff Member # 27 stated "They (Patient Right's) are posted throughout the hospital and we do not give them a copy or ask if they want a copy." Surveyors observed patient rights signs posted throughout the hospital, though they were not always visible to patients as some were posted behind objects such as plants, and the patient rights signs were noted to be in small print and in the English language.

The facility's policy provided by Staff Member # 6 on August 30, 2017 at approximately 4:00 P.M. titled "Patients Rights and Responsibilities Policy and Procedure" reads in part " Upon admission, patients will be given a copy of the "Patient's Rights and Responsibilities Statement". This information shall be reviewed as needed with the patient and/or family by the admitting nurse or designee. Effort will be made to assure that this information is provided in a manner that can be understood by the patient and/or family. Resources to assist patients with special needs, i. e., visual impairment, inability to read, or non-English speaking. Documentation that the Statement of Patient Rights and Responsibilities has been presented to the patient and/or family and that the patient and/or family has had an opportunity to ask questions or receive clarification is provided by placing a check in the "Patient Handbook/Patient Rights & Responsibilities" area on the Nursing Admission Assessment form."


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2. On 8/19/17 Patient #2 requested to be transferred to another hospital where Patient #2's cardiologist practiced. Patient #2's attending physician was interviewed on 8/30/17 at 10:15 A.M. via telephone and stated, "I was more than happy to transfer the Patient but the Patient was going to have to find an accepting physician. I cannot transfer a patient to another hospital without an escalation of care. In this case it would have been a lateral transfer. Once the family found an accepting physician I called the physician gave them a report and called the transfer center to get a bed."

A review of Patient #2's medical record was performed on 8/29 and 30/17. The record review revealed the following:
The attending physician's progress note was dictated at 5:36 P.M. on 8/19/17. The transportation department was not notified of the transfer request until between 9:15 and 10:45 P.M. Patient #2 was discharged at 2:28 A.M. on 8/20/17.

Based on observation and interview it was determined the facility failed to ensure the privacy of patients who were seeking care and services in the Emergency Department (ED). Questions were being asked, including the reason for seeking treatment, in an open area were other patients and staff could overhear the replies of patients.

The findings include:

On 8/28/17 at approximately 2:25 P.M. during the initial tour of the ED Staff Member #7 was asked if a patient arrived complaining of an assault where would the triage take place. Staff Member #7 stated, "Here (just behind the open registration desk, next to the open doorway and across from the small waiting area)". Walking past the registration desk was an open door way that led into a larger waiting area to the left. A hallway to the far left past the security guard, led down to other triage/exam rooms.

During the ED tour all rooms were occupied and all stretchers in the hallway were filled.

As a person entered the ED doors to the immediate left was a small registration desk in an L shape. Directly behind the desk in an open area was a chair, vital sign machine and other various equipment used in triage. Across from the registration desk was a small 6-8 chair waiting area. Staff Member #6 stated, "When some one needs monitoring until a bed/stretcher is available they will sit there so the triage nurse can monitor them."

Staff Member #32 and 33 were interviewed together on 8/30/17 at approximately 11:54 A.M. Both stated the area being used for triage was not intended for triage or interviews. Staff Member #32 stated, "There are 4 rooms in the old fast track area where triage should occur. The area behind registration is not intended for interviews or vital signs."

Staff Member #33 was asked if the triage nurse leaves the registration desk area to go to one of the fast track rooms, who monitors the patients waiting in the small waiting area. Staff Member #33 stated, "Obviously we are still working on some logistics." Staff Member #32 stated, "The construction on the ED began on June 8th (2017)."

Based on observation, interview, and document review, it was determined the facility failed to provide care in a safe environment for one (1) of one (1) patients. (Patient # 23).

The findings include:

On August 28, 2017 at approximately 2:30 P.M. during a tour of the Emergency Department (ED), Patient # 23 was observed entering the facility's ED for care. Patient # 23 was ambulating with a walker. Staff Member # 7 was observed asking Patient # 23 to sit in a chair behind a desk to obtain vital signs. Patient # 23 was unable to get the walker in between the desk and the wall to reach the chair. Patient # 23 was observed holding on to the desk and the chair in order to reach the chair and sit down. Staff Member # 7 sat at the desk and did not get up to try to help Patient # 23.

An interview on August 31, 2017 at approximately 10:00 A.M. with Staff Member # 1 revealed that the ED triage is intended to take place in a room, not at the desk. Staff Member # 1 stated "It was not intended for a patient to be behind the desk and it is expected that the staff will assist patients as needed".

The facility's "Patient Rights and Responsibilities" provided by Staff Member #27 on August 30, 2017 at approximately 3:35 P.M. reads in part "You have the right to considerate, safe and respectful care".

Based on observations, interviews, and review of documents, it was determined the facility staff failed to ensure restraint orders identified specifically which parts of the patient's body were to be restrained and/or the clinical reason the restraints were ordered for two (2) of four (4) patients sampled for restraint use (Patient #19 and Patient #21).

The findings include:

1. Patient #21 was observed to have bilateral upper extremity soft limb restraints in use on the afternoon of 8/28/17.

The following order was documented in Patient #21's clinical record on 8/27/17 at 3:17PM: "Restraints - Non-violent ... Type: Soft limp ... Time limit: 1 day ... Reason/clinical need: Integrity of lines/tubes". This order was renewed on: 8/28/17 at 9:31AM, 8/29/17 at 10:35AM, and 8/30/17 at 9:26AM. These orders failed to identify which limb or limbs were to be restrained. Patient #21's clinical documentation indicated bilateral upper extremity soft restraints were applied.

The following information was found in a facility policy and procedure entitled "Restraint and Seclusion" (with an issue date of 8/1994 and the most recent revised date of 5/2016): "Restraints Used to Manage Non-Violent / Non-Self-Destructive Behavior ... Order - Restraint intervention must be ordered by a Physician or LIP (licensed independent practitioner) responsible for the care of that patient ... Order must include: 1. Reason for application 2. Type of restraint 3. Time limit ..."

The failure of the facility staff to ensure the physician restraint order identified which limbs required restraints was discussed with the facility's Quality Coordinator (Staff Member (SM) #3) on the afternoon of 8/30/17. SM #3 reported that for the order to detail which limbs to restrain the individual entering the order would have to put it in "as a miscellaneous order".

2. Patient #19's clinical record included a handwritten order dated 7/15/17 at 8:15PM for "Soft limb restraints".

This order was given to a nurse by a prescriber; documentation did not address if it was a verbal order or a telephone order. The order did not identify which limb or limbs were to be restrained. The order did not identify the reason for the restraints. This handwritten order had been transcribed and entered into the facility's electronic documentation on 7/15/17 at 10:16PM. When entered into the electronic record the order was marked as a telephone order. The facility's Chief Medical Informatics Officer (CMIO) was interviewed on 8/29/17 at 3:00PM. The CMIO reported the only option when transcribing handwritten orders into the electronic record is to mark it as a telephone order. Therefore it is unknown if the order was a telephone order or a verbal order.

Patient #19's clinical documentation indicated bilateral upper extremity soft restraints were applied.

Patient #19's restraint order was reviewed with SM #3 (Quality Coordinator). SM #3 acknowledged the orders did not include which specific limb or limbs were to be restrained.

Based on interview and personnel record review,it was determined the facility failed to require staff to have education, training and demonstrate knowledge based on the specific needs of the patient population for one (1) of eight (8) Staff Members (Staff Member # 11).

The findings include:

On August 28, 2017 at approximately 3:25 P.M. during a tour of the Emergency Department (ED), Staff Member #11 was observed sitting at a desk outside of two patient rooms in the a locked area of the ED. Staff Member # 9 stated that the area was for patients with mental illness.

An interview on August 28, 2017 at approximately 3:30 P.M. with Staff Member #11 revealed that he/she was a Patient Care Technician (PCT)/Certified Nursing Assistant (CNA) on the surgical unit of the facility. When asked if a patient grabbed him/her by the hair would he/she know what to do, Patient # 11 stated "I would do my best to get away". Staff Member #11 stated he/she had no training in taking care of patients with mental illness.

On August 31, 2017 at approximately 9:00 A.M. a personnel record review for Staff Member # 11 revealed training for a PCT/CNA on the surgical unit only; no training for patients with mental illness.

An interview on August 31, 2017 at approximately 10:00 A.M. with Staff Member #1 revealed "the staff in that area (mental illness patients) should have training in taking care of patients with mental illness".

Based on interview and document review, it was determined the facility staff failed to ensure the nursing plan of care which includes the physician's order were followed for 1 of 22 patients, Patient #2.

The findings include:

Patient #2's medical record was reviewed on 8/29/17. Patient #2 who was initially seen in the ED on 8/18/17 at 10:36 P.M. for increased Troponin level (0.46 ng/mL (nanograms per milliliter) and syncope and was documented at a Priority 2 Urgent and placed on room air. Troponin is a protein that's released into the bloodstream during a heart attack.

One (1) inch of Nitrobid paste was ordered and applied at 1:52 P.M.. A physician's order to place Patient #2 on 2L (liters) of oxygen was written on 8/19/17 at 12:07 A.M. via nasal cannula. Patient #2 was placed on 2L of oxygen at 1:14 A.M., an hour and seven minutes after the physician's order.

Also on 8/19/17 at 12:07 A.M. the physician ordered the following blood pressure monitoring: If systolic blood pressure less than 90 or greater than 190 and diastolic is greater than 105 contact the physician.

The Troponin level was repeated with the result of 0.157 ng/mL (a critical value) called to the ED at 1:14 A.M.
At 1:16 A.M. on 8/19/17 the physician placed an order to resume Patient #1's home medications of Metoprolol 100 mg (milligrams) twice a day.
Patient #1 was admitted to PCU (Progressive Care Unit) at 1:54 A.M.

Vital signs were performed at the following times:
On 8/18/17 First set of vital signs was performed at 10:39 P.M. with a blood pressure of 205/86 pulse of 84, respirations of 20 and pulse ox of 97.
8/18/17 at 10:40 P.M. blood pressure 201/89. One hour and 4 minutes later a third blood pressure was obtained at 11:44 P.M. blood pressure 186/84. The forth blood pressure was obtained at 1:14 A.M. an hour and one half later with a blood pressure of 168/79.
8/19/17 at 1:56 A.M. blood pressure 150/69
8/19/17 at 6:51 A.M. blood pressure 146/67
8/19/17 at 10:03 A.M. blood pressure 162/70
8/19/17 at 12:30 P.M. blood pressure 164/72
8/19/17 at 2:37 P.M. blood pressure 197/83 right arm and 193/77 left arm there was no evidence the physician was notified of the elevated blood pressure
8/19/17 at 3:25 P.M. blood pressure 181/77
8/19/17 at 4:08 P.M. blood pressure 183/75
8/19/17 at 4:48 P.M. blood pressure 173/74
8/19/17 at 5:28 P.M. blood pressure 182/76
8/19/17 at 6:50 P.M. blood pressure 155/67
8/19/17 at 9:24 P.M. blood pressure 131/60

Patient #1 was transferred to another facility on 8/20/17 at 2:28 A.M. There was no nursing discharge note.

The Policy titled Discharge Planning with a last review date of 12/14 was provided on 8/29/17. Documented under Standard of Practice bullet 3 states, "Discharge instructions given to the patient/family/caregiver will also be provided to the individual or organization responsible for the continuing care of the patient. Staff Member #5 was interviewed on 8/30/17 at approximately 9:30 A.M. and stated, "There should have been a nursing discharge note and a more current set of vital signs documented."

Per the facility policy: Vital Sign Policy last review date of 11/15 documents under Frequency of Re-Assessment the following: Bullet #2, Priority 3: "These patients will receive an initial set of vital signs and a re-check of vital signs every 2 hours and an additional set prior to discharge/transfer/or admission.
Bullet #3, Priority 2: These patients will receive an initial set of vitals and a re-check of vital signs every hour and an additional set prior to discharge/transfer/or admission."

Based on interviews and review of documents, it was determined the facility staff failed to ensure clinical documentation was complete and accurate for two (2) of twenty-two (22) sampled patients (Patient #8 and Patient 19).

The findings include:

1. Patient #8's clinical documentation included orders entered by a nurse that was provided by a prescriber; these orders did not include documentation to indicate if the orders were telephone orders or verbal orders.

Patient #8's clinical documentation included the following orders:
- An order dated 5/8/17 at 1:15PM. This order was for Enalapril 10mg orally one tablet now. A nurse had documented this order was given by a prescriber. The nurse did not document if the order had been given verbally or via the telephone. The nurse did not document if the order was 'read-back' to the prescriber.
- An order dated 5/8/17 at 1:44PM. This order was for Percocet one or two tablets orally as needed for pain. The nurse did not document if the order had been given verbally or via the telephone. The nurse did not document if order was 'read-back' to the prescriber.
- And order dated 5/8/17 at 2:00PM. This order read as: "OK to release (patient) (with) BP (blood pressure) 189/84 - 65 - 22". The hand written order did not include the name of the provider giving the order and did not include the name of the nurse accepting the order. The nurse did not document if the order had been given verbally or via the telephone. The nurse did not document if the order was 'read-back' to the prescriber.
- An order dated 5/8/17 at 3:00PM. This order was to discharge the patient with "attention to BP (blood pressure) (with) Primary care provider" [sic]. The nurse did not document if the order had been given verbally or via the telephone. The nurse did not document if the order was 'read-back' to the prescriber.

The facility's Chief Medical Informatics Officer (CMIO) was interviewed on 8/29/17 at 3:00PM. The CMIO acknowledged the aforementioned orders did not indicate if the orders were telephone orders or verbal orders. The CMIO acknowledged the aforementioned orders did not indicate the order had been 'read-back' to the prescriber when the order was obtained/documented by the nurse.

The following information was found in a facility policy/procedure entitled "Verbal and Telephone Order Policy" (with an issue date of 1/2003 and a most recent revised date of 2/17):
- "If the physician or practitioner is present, they must write the order on the patient's chart or input into the computer (unless physically restricted, i.e. sterile procedure, etc.)."
- "The staff member will take the telephone order and write it down. After writing the telphone [sic] order it will be read back to verify that it is correct."
- "A Telephone order will be written as: -T.O. Dr. Sam Smith/Nurse Jones RN".
- "A Verbal order will be written as: -V.O. Dr. Sam Smith/Nurse Jones RN".
- "The date and time is required by the person writing the order. The date and time will also be documented by the person who signs off/verifies the order."
- "It is recognized that verbal orders are given in Code, ER and OR situations where it may not be feasible to do a formal "read back". The RN giving the medication or treatment will repeat back the order and the recorder will document the name of drug/treatment with the dose, time, route, and rate. In these situations the "repeat back" is acceptable."
The "Verbal and Telephone Order Policy" was reviewed with the facility's Director of Quality (Staff Member (SM) #2). SM #2 stated the policy does not require the documentation of 'read back' when obtaining a telephone order.

2. Patient #19's clinical record included a restraint order documented by a nurse that was provided by a prescriber; this order did not include documentation to indicate if it was a telephone order or a verbal order. Patient #19's restraint order was reviewed with SM #3 (Quality Coordinator) on 8/30/17 at 9:55AM.

The restraint order was dated 7/15/17 at 8:15PM. It was for "Soft limb restraints". The nurse did not document if the order was a verbal order or a telephone order. The nurse did not document if the order was read-back to the prescriber. This handwritten order had been transcribed and entered into the facility's electronic documentation on 7/15/17 at 22:16. When entered into the electronic record the order was marked as a telephone order. The facility's Chief Medical Informatics Officer (CMIO) was interviewed on 8/29/17 at 3:00PM. The CMIO reported the only option when transcribing handwritten orders into the electronic record is to mark it as a telephone order. Therefore it is unknown if the order was a telephone order or a verbal order.