HospitalInspections.org

Based on observation, staff interviews, clinical record and administrative document review, the hospital failed to have an effective governing body legally responsible for the conduct of the hospital when:

1. Nursing care in the emergency department (ED) was not provided in accordance with hospital policies and procedures. The ED nursing staff did not fully implement Standardized Procedure orders for three of 37 sampled patients, Patients 1, 13, and 24. (refer to A 0385 and A 0392)

2. The Advance Directives (AD- also known as living will, personal directive, advance directive, medical directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness) for patients were not immediately accessible in the medical record. There was non-compliance with the facility policy and procedure for abiding by patient wishes for Advance Directives. (refer to A 0132)

3. Medical Records were not completed within the required timeframe, policy and procedure for verbal orders was not followed, and medical records could not be accessed during an electronic health record outage. (refer to A 0438, A 0450, A 0454)

4. Policies and procedures for the care of patients in the ED were not evaluated and updated on an on-going basis to ensure standardized procedures were current and being fully implemented by nursing staff. (refer to A 1104)


The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe environment.

Based on observation and record review, the Advance Directive (AD- also known as living will, personal directive, advance directive, medical directive or advance decision, is a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness ) of patients were not immediately accessible in the medical record. There was non-compliance with the facility policy and procedure for abiding by patient wishes for Advance Directives. During the outage of the Electronic Health Record (E.H.R.) system on 5/15/18 and 5/16/18, the presence of an AD could not be determined as these documents were electronically scanned into the E.H.R., and after scanning the hardcopy stored in the HIM department and not immediately accessible.

An observation of the HIM department on 5/14/18 where hardcopy documents were kept after being scanned into the E.H.R., copies of ADs were mixed in within stacks of other paper documents, which were only organized by date of scanning, and not easily accessible or identifiable.

An observation of a patient medical record displayed in the E.H.R. showed a yellow banner on the top of each computer screen viewing which provided identifiers such as the patient name, medical record number, age sex and date of birth, code status (whether efforts should be resuscitate the patient in heart failure), Adv Care Plan/POLST (advance care directive with Physician Order for Life Sustaining Treatment), date of admission, attending provider, height and weight, among other identifiers.

An interview with the head nurse (CT1) on the Cardiac Telemetry unit located on the third floor was conducted to determine whether the code status of each patient was known while the E.H.R. system was down. There was no immediate access to the status or the AD which described patient wishes without access to the E.H.R Code status of Do Not Attempt Resuscitation (DNaR) was solely based upon what was indicated on the patient ID wrist bracelet at the time of admission to the hospital or on the status board in the patient room.

In an interview on 5/16/18 with the Social Service director (SSD), he stated that the hardcopy version of an AD if provided by a patient was kept for 30 days prior to the form being destroyed in the HIM department. This information was not widely communicated to nursing staff.

A review of the facility "Advance Health Care Directive/ Advance Directive (Medical) (IPPC)" policy and procedure provided on 5/15/18 contained the statement that "it is the policy of MMC to honor all Advanced Medical Directives outlined by each patient".

A review of the medical record for patient 26, a 94 year old patient, had an AD from 10/8/09 which was signed but incomplete as to the patient wishes. A DNaR order by the physician provider on 4/3/18, was later cancelled. The Code Status history in the E.H.R. showed conflicting information "Full (resuscitation)" on 4/7/18 and 4/9/18 and "Do Not Attempt Resuscitation (DNaR)" on 4/3/18 and 4 /7/18. A Palliative Care Consultation on 4/13/18 reflected a DNaR code status without any POLST by the provider. A review of a sample Code Status History screen shot (a reproduction of what was viewable from the E.H.R. on a computer terminal) from the E.H.R. of patient 26 indicated the 5 different entries that were confusing without any clarifying documentation in the Comment section.

In a review of the medical record for patient 27, the POLST was stamped with a physician name & address, yet the physician did not sign the order on 3/14/16 and the physician license number was not listed, making the order invalid, while the POLST order indicated "Do Not Attempt Resucitation/DNR". Order #888748845 for patient 27 in the medical record on 4/10/17 indicated "Attempt FULL resuscitative efforts (No restrictions)" in contradiction to the POLST.

A review of the medical record for patient 29, 62 year old male admitted via the ED, had no admission information flow sheet secured regarding the patient's wishes regarding an AD, contrary to facility policy for an inpatient admission. A Critical Care progress note of 4/15/18 from the E.H.R. was provided which stated that the patient "wrote down on paper he would like to die" yet the documentation was not provided in the E.H.R. This patient expired on 4/16/18.

A review of the medical record for patient 31, 87 year old male, had an AD /Living Will from 2007, and a Physician Orders for Life Sustaining Treatment (POLST) for 4/15/18 The 4/13/18 order in the E.H.R. indicated "cancelled".

A review of a sample Advance Health Care Directive form provided on 5/14/18 provided instruction that pateints be able to specify alternative individuals to make health care decisions, direct the provision of artificial nutrition or hydration and other patient wishes regarding medical treatment.

Based on interview, record and administrative document review, the hospital failed to ensure the provision of nursing services when:

1.The Emergency Department (ED) nursing staff did not fully implement Standardized Procedure orders for three of 37 sampled patients, Patients 1, 13, and 24. (Refer to A 0392)

2.The ED triage nurse did not prioritize stat (urgent) lab test orders for one of 37 sampled patients, Patient 1.(Refer to A 0392)

3. The ED nursing staff did not prioritize patients with chest pain for prompt evaluation by an ED provider (Physician, Physician's Assistant, Nurse Practitioner), for two of 37 sampled patients, Patients 1 and 24. (Refer to A 0392)

4. The ED nursing staff did not ensure a patient with suicidal thoughts was closely observed prior to evaluation for one of 37 sampled patients, Patient 13. (Refer to A 0392)

5. The ED nursing staff did not ensure patients undergoing testing or receiving care in the emergency department were observed or monitored while waiting in the lobby for two of 37 sampled patients, Patients 1 and 24. (Refer to A 0392)


The cumulative effect of these systemic problems resulted in the hospital's inability to provide quality health care in a safe environment.

Based on interview, clinical record, and administrative document review, the hospital failed to provide nursing care in accordance with the hospital's policies and procedures when:

1. Patient 1 presented to the Emergency Department (ED) on 3/28/18 at 5:40 a.m. with the chief complaint of Chest Pain (pain level of 8 on a scale 0 to 10) and history of high blood pressure. The triage Registered Nurse (RN 1) assessed Patient 1, obtained her blood pressure of 186/120 (normal range 120/80-140/90), and determined the Emergency Severity Index (ESI: a five-level triage system that categorizes emergency department patients by evaluating both patient acuity and resources [tests, procedures, or treatments likely to be utilized in order to determine the disposition of a patient]) as Level 3. RN 1 initiated, but did not completely implement the Chest Pain standardized procedure (SP), did not prioritize Patient 1 to be seen by a provider (Physician, Physician's Assistant, Nurse Practitioner), did not prioritize obtaining the blood samples for the lab tests ordered, and had Patient 1 wait in the lobby.

2. Patient 24 presented to the ED on 2/6/18 at 10:44 a.m. with the chief complaint of Chest Pain (pain level of 10 on a scale of 0 to 10). The triage Registered Nurse (RN 9) assessed Patient 24 and determined the ESI as Level 3, initiated but did not completely implement the Chest Pain SP, did not prioritize Patient 24 to be seen by a provider, and had Patient 24 wait in the lobby.

3. Patient 13 presented to the ED via ambulance on 1/25/18 at 10:13 a.m. with the chief complaint of suicidal ideation with depression. Patient 13 was triaged and prioritized with an ESI of 2 and placed in Hallway 7 bed. The SP for psychiatric complaints was initiated but not fully implemented.

These failures resulted in a delay in evaluation and treatment of Patients 1,13, and 24 by a medical provider.

Findings:

1. Review of Patient 1's clinical record indicated:
On 3/28/18 at 5:40 a.m., Patient 1, a 41 year old female, arrived via private car to the hospital's Emergency Department (ED) and checked in with RN 1. Patient 1 provided RN 1 the chief complaint that she had been experiencing chest pain for three days described as burning, tightness and intermittent. Patient 1 described her current pain level as 8 on a scale of 0 to 10. RN 1 assigned Patient 1 an ESI of 3.

5:43 a.m.: RN 1 initiated orders from the Chest Pain Standardized Procedure (SP: a protocol for RNs which allows for ordering diagnostic studies and providing initial treatment in specific situations prior to a patient being examined by a provider [physician/physician's assistant/nurse practitioner]) as follows: Blood tests for Troponin I (a protein released when the heart muscle is damaged), CBC (complete blood count), Metabolic Panel (Test measuring blood sugar levels, electrolyte and fluid balance, kidney function, and liver function), 12-lead Electrocardiogram (EKG or ECG-looks at electrical activity in the heart), Chest X-ray, and a urine pregnancy test. RN 1 did not initiate orders for cardiac monitoring, or placing an intravenous line (IV-inside the vein). RN 1 did not perform a focused assessment, obtain a history to identify cardiac risk factors, describe characteristics of pain, or identify all medications taken.

5:45 a.m.: RN 1 obtained the following vital signs from Patient 1: temperature of 96.8 degrees Fahrenheit, a pulse of 75 beats per minute (bpm), respiratory rate of 20, oxygen saturation of 98 percent, and a blood pressure (BP) of 186/120. RN 1 documented next to the blood pressure value: "history of hypertension (high blood pressure), took meds prior to arrival".

5:53a.m.- 6:00 a.m.: Chest x-ray completed.

6:02 a.m.:12-lead EKG completed.

6:07 a.m.: An ED Medical Doctor (MD 1) reviewed the EKG, initialed and marked on the EKG form "no STEMI" (ST elevation myocardial infarction [heart attack]). The EKG automated interpretation was "left axis deviation, ventricular hypertrophy with QRS widening and repolarization abnormality, inferior infarct, age undetermined, anterolateral infarct age undetermined, abnormal ECG [EKG]."

After the EKG was completed, Patient 1 waited in the lobby.

7:09 a.m.: Patient 1 was in Rapid Medical Evaluation (RME) room 2 with RN 2.

7:42 a.m.: Blood samples sent to the lab by RN 2.

7:45 a.m.: BP 128/93 and pulse of 109 bpm.

8:00 a.m.: BP 128/108.

8:02 a.m.: Patient 1 is at the registration desk.

8:04 a.m.: Physician Assistant (PA) 1's note indicated he reviewed Patient 1's record, obtained a brief history, and performed a limited exam. PA 1 documented "...Patient 1 has a history of hypertension ... presents to the ED for evaluation of intermittent left sided chest pain for three days described as burning and tightness with shortness of breath on inspiration (breathing in). Reports episodes of chest pain this morning that lasted approximately 1.5 hours. Reports being awoken by chest pain...." PA 1 discussed the EKG results with MD 2 and documented: "no STEMI but concerning findings" and a plan to place Patient 1 in a "bed in the back" (bed in the ED core).

8:10 a.m.: Registration completed. The record does not indicate Patient 1 was observed again after registration.

8:11 a.m.: RN's note indicated the plan to put Patient 1 in a bed in the back.

8:38 a.m.: Critical lab result for troponin was reported to PA 1; the troponin level was 3.3 (normal range is 0.00 to 0.05).

8:42 a.m.: RN 2 documented "...attempted to take to room in main ED, patient not found, lobby, bathrooms; multiple attempts to locate patient unsuccessful. Called phone number on chart, no answer at this time ... PA aware; charge nurse aware."

8:45 a.m.: RN 2 documented "...Attempted to find patient in lobby X 2 (twice); unable to find patient or boyfriend."

10:15 a.m.: Record indicated Patient 1 as discharged.

12:49 p.m.: Patient 1 arrived in ED. Triage RN (RN 11) assigned Patient 1 an ESI of 2. BP 136/86.

12:53 p.m.: To Room 37 in ED core.

12:59 p.m.: Patient 1 placed on cardiac monitor, non-invasive blood pressure monitor and continuous pulse oximetry.

1:01 p.m.: EKG completed. Automated interpretation noted as "Sinus tachycardia (rapid heart beat), T-wave abnormality, Abnormal ECG [EKG]". Pain assessment was 3 out of 10. Chest X-ray was done.

1:18 p.m.: MD 2 obtained Patient 1's history of methamphetamine use, last use yesterday. Also noted family history of cardiac disease; father had MI at 40 y/o.

From 1:19 p.m. until 2:45 p.m. the care of Patient 1 included blood draw for lab tests, placement of intravenous access and administration of medications including Aspirin, Ativan, Clonidine, nitroglycerin, diltiazem, potassium chloride and heparin (medications that are part of the protocol for patients having a heart attack).

2:05 p.m.: Critical lab value of Troponin 8.55 (range 0.00-005) was reported, as well as Pro-Brain Natriuretic Peptide (PROBNP- a protein present in heart failure) of 1,270 pg/ml (Normal range: 0-450 pg/ml)

2:45 p.m.: MD 2 indicated decision to admit. Diagnosis: Non-STEMI (non-ST elevated myocardial infarction).

4:04 p.m.: Patient 1 was admitted to the telemetry (unit where patients hearts are continuously monitored) unit on the second floor.

2. Review of Patient 24's clinical record indicated:

On 2/6/18 at 10:44 a.m., Patient 24, a 90 year old non-English speaking female, arrived by car to the hospital's ED and checked in with triage nurse (RN 9). Patient 24's chief complaint was documented, "patient came in with chest pain that began last night; patient also states cough with sputum production for the past 2 months." Patient 24's chest pain level documented at 10 on a scale of 0-10. Blood Pressure at triage was 133/63, pulse 66 bpm and Temp 36.4 degrees Celsius. Oxygen saturation 95 %.

10:47 a.m.: Triage completed. Patient 24 assigned an ESI of 3. After triage was completed, Patient 24 waited in the lobby.

10:49 a.m.: Standardized procedure for chest pain initiated and orders placed for laboratory tests, chest x-ray, and EKG. The record did not indicate the use of a cardiac monitor or placement of an IV.

10:56 a.m.: EKG completed. Screening by ED physician indicated no STEMI (ST elevation myocardial infarction).

11:07 a.m.: Blood samples obtained and sent to the lab.

11:40 a.m.: Chest x-ray completed. Results within normal limits for patient. Patient to wait in lobby.

11:41 a.m. to 2:29 p.m. - There is no documentation of observation or location of Patient 24 during this time. No indication vital signs obtained or cardiac monitoring done.

2:29 p.m.: Patient 24 was taken to the RME (Rapid Medical Evaluation) room to have a Medical Screening Exam (MSE: an exam to determine if an emergency medical condition exists) performed. Patient 24's chest pain level was a 6 on a scale of 0-10. Patient was alert and had a frequent cough. Nurses notes indicate "Patient [Patient 24] c/o chest pain on and off over the past couple of months. Patient states she had chest pain all night and continued today that was worse than normal. Patient has had a cough for the last three weeks."

3:02 p.m.: MSE performed by MD 3.

3:12 p.m.: Patient 24 received an albuterol breathing treatment (medication used to prevent and treat breathing difficulties, shortness of breath and coughing). Oxygen saturation 96%, pulse 65, respiratory rate 20/minute. No blood pressure value recorded. Patient moved to internal waiting room.

3:21 p.m.: Results of lab test D Dimer (blood sample that measures whether or not there are blood clots present in the blood) returned elevated at 597 (normal range less than 250).

3:39 p.m.: Chest Computed Tomography (a diagnostic imaging test to examine organs, soft tissue, blood vessels, and bones) with contrast (dye) was ordered by MD 3.

4:28 p.m.: Final result of the EKG performed at 10:51 a.m. was entered into the ED record. Diagnosis: "Atrial fibrillation [an irregular heart rhythm occurring when the top chambers of the heart beat out of coordination with the lower chambers] with a competing junctional pacemaker, left anterior fascicular block [blockage of one of the electrical branches that delivers electrical signals to a part of the left ventricle, one of two chambers in the heart], abnormal ECG. When compared with ECG of June 2017, atrial fibrillation has replaced sinus rhythm." The record does not indicate whether an ED physician was aware of the EKG results or discussed the findings with Patient 24.

4:41 p.m.: RN 6 indicated Patient 24 wanted to go home prior to the Chest CT exam and RN 6 informed MD 3.

5:43 p.m.: RN 6 indicated Patient 24 was upset at wait times, refused CT of the chest and requested to leave Against Medical Advice (AMA). MD 3 was notified via phone; did not speak with Patient 24 or family. Patient 24 signed AMA form using language line interpreter # 183500 and Pt 24 left with her son. RN 6 indicated instructions were not provided to Patient 24 prior to her leaving the hospital.

The record did not indicate Patient 24's vital signs were obtained after 3:12 p.m., a chest pain level assessed after 2:35 p.m., or use of a cardiac monitor during Patient 24's ED visit.

3. Review of Patient 13's clinical record indicated:

On 1/25/18 at 10:13 a.m., Patient 13 a 28 year old male brought in by ambulance (BIBA) to the hospital's ED with a chief complaint "suicidal ideation [SI] [thinking about or planning suicide], and depression [A mental health disorder causing persistent feelings of sadness that affect a person's daily life]."

10:19 a.m.: Triage completed with Patient 13 assigned an ESI of 2, and placed in hallway bed 7. Triage nurse indicated, "+ Suicidal Ideation [BIBA from home for feeling depressed, voluntary 5150 hold per EMS. No plans of hurting himself at this time per pt.]"

10:20 a.m.: Nursing assessment indicated Patient 13 was alert and oriented with a depressed mood.

10:43 a.m.: Vitals signs obtained were within normal limits.

10:48 a.m.: Orders initiated per the Standardized Procedure for psychiatric complaints, including a metabolic panel, complete blood count (CBC), urinalysis (UA), and blood tests for alcohol, salicylate (aspirin), and acetaminophen (Tylenol). Urine drug screen was not obtained. The record does not indicate an intravenous line (IV) was ordered or a cardiac monitor.

10:54 a.m.: A chart entry indicated a physician was assigned to Patient 13, however the record does not indicate Patient 13 was seen by a provider.

10:55 a.m.: Urine specimen obtained. No further documentation of contact or observation of Patient 13 within the ED.

11:22 a.m.: RN 7 indicated, "...Pt [Patient 13] unable to find in bed. Public safety informed. Pt not in lobby...Charge Nurse informed and aware...."

11:26 a.m.: RN 8 indicated,"...Attempted to call pt's cell phone listed...unable to leave voicemail... [local town] PD contacted to notify them of patient elopement...." No documentation of the provider being notified. PT 13 discharged in computer and given the disposition of elopement.

On 5/16/18 at 11 a.m., during a concurrent interview and clinical record review, RN 8 stated she was working on 1/25/18 as charge nurse when Patient 13 was in the ED. RN 8 stated a staff nurse informed her Patient 13 eloped, and RN 8 contacted the police department. RN 8 did not know if a "sitter" (a staff person assigned to be physically present to observe patient at all times) was requested for Patient 13; the record did not indicate that a sitter was present. RN 8 stated if a sitter is needed, an ED tech can assume this role, or the staff call the house supervisor to request help.

On 5/16/18 at 11:05 a.m., during a concurrent interview and record review, RN 7 stated she was the triage RN for Patient 13 on 1/25/18. RN 7 recalled that Patient 13 was BIBA after calling 9-1-1 because he (Patient 13) stated he wanted to hurt himself. RN 7 stated when Patient 13 arrived to the ED, her assessment was Patient 13 did not have a "plan" to hurt himself. RN 7 assigned Patient 13 an ESI of 2. RN 7 stated she was told no other beds were available so Patient 13 was put in hallway bed 7. RN 7 stated she was familiar with the standardized procedures and they usually do follow them to help expedite the care. RN 7 stated she did not initiate all of the orders in the standardized procedure though because "they can pick and choose" which ones to implement. RN 7 stated she did not see Patient 13 leave the department; she found out he was gone when staff from the lab asked where Patient 13 was. RN 7 stated as far as she knows no staff in the ED saw Patient 13 leave. When asked what safety measures were implemented for Patient 13, RN 7 stated "He needed a sitter to be with him." RN 7 stated Patient 13 had been in ED "less than an hour" and they "eventually would get him a sitter." RN 7 stated she notified the physician when Patient 13 left; she just did not document that.

On 5/14/18 at 10:15 a.m. during an observation in the ED triage area and lobby (external waiting room), approximately 15 patients wearing identification bands on their wrists sat in chairs in the lobby. Some of the patients were observed with disposable blood pressure cuffs wrapped around their upper arms; no saline locks. None of the patients appeared to be in any distress. A female patient was observed in a wheelchair at the triage desk accompanied by a friend. The triage RN greeted the patient and obtained the chief complaint of heart palpitations and chest pain/discomfort. The triage RN took the patient's vital signs and informed the patient her heart rate was elevated. The patient stated she has atrial fibrillation (an irregular heart rhythm occurring when the top chambers of the heart [atria] beat out of coordination with the lower chambers [ventricles]). The triage RN called the charge nurse immediately to inform her about this patient's condition and symptoms. Approximately two minutes later, the charge nurse arrived at the triage desk and transferred the patient back to the RME (Rapid Medical Evaluation) area to be seen by a provider.

On 5/14/18 at 10:25 a.m., during a concurrent observation and interview in the ED triage area and lobby, the ED Manager (EDM) stated they had been working hard to make changes in the ED in response to the issues previously identified concerning Patient 1's care. The EDM explained the recent changes made: The hospital's policies and procedures related to ED care had "just been revised this past week." The EDM stated the D-Pod (an area in the ED core containing eight monitored beds) has been re-opened which means more patients can be put in ED beds, and fewer patients will have to wait out in the lobby in various stages of the evaluation process.The EDM stated D-Pod is now open Mondays, Tuesdays, and Thursdays. The EDM stated these days were chosen based on evaluating the patient volume over time. The EDM stated she obtained approval for additional RN positions with the goal being to keep D-Pod open all of the time. The EDM stated all ED nursing staff have been re-educated on the use of standardized procedures. The expectation is all orders in the appropriate SP will be initiated if the estimated wait time prior to the patient seeing a provider exceeds 30 minutes. The EDM stated all staff have been re-educated that if there is not a phlebotomist assigned to the ED to draw blood for lab tests, they can call the lab for assistance or draw the blood sample themselves; they are not to delay obtaining the blood sample. The EDM stated ED nursing staff were also re-educated to the fact that there is always a provider in the ED 24 hours a day. If the provider is not in Triage or the RME area, they will be in the ED core. The EDM stated another change they have made is patients who have been triaged and assigned an ESI Level 2, will not be put in the lobby except on rare occasions. All patients with an ESI Level 2, and patients with abnormal vital signs will be escalated by the triage nurse in order to be seen by the provider in a timely manner. The EDM stated they have changed the responsibilities of a couple of the RNs who were previously assigned to help out in the ED core and now they are responsible for checking on the patients in the lobby who are waiting to see a provider, or have lab tests or x-rays done, etc. The EDM stated another change they have implemented is putting a registration clerk in the ED so the patients will not have to leave the area to register any longer and there is less chance they will leave altogether.

On 5/15/18 at 2:10 p.m. during a concurrent interview and observation of the ED lobby, none of the patients waiting in the lobby were observed to have saline locks. The charge nurse (RN 13) stated patients with "saline locks are not allowed in the lobby...this practice changed when the policy changed...."

On 5/15/18 at 14:18 p.m., during a concurrent inerview and observation in the ED, RN 14 stated no high acuity patients are allowed to wait in the lobby, must be in the RME area. RN 14 stated "a week ago this was changed." RN 14 stated patients with chest pain are not put in the lobby.

The hospital policy and procedure titled, "Triage Policy" dated 5/14/16, indicated, "...DEFINITION: A. TRIAGE: is a process by which patients who present to the Emergency Department (ED) are assessed and prioritized for a Medical Screening Exam. Triage determines the time order sequence in which a patient should be seen through assessment of severity of complaint using the Emergency Severity Index (ESI) five-level triage system. B. ESI: A five-level triage system that categorizes emergency department patients by evaluating both patient acuity and resources... C. RESOURCE: a diagnostic test, procedure and therapeutic treatment that is likely to be utilized in order to make a disposition of the patient ...Labs, EKG, X-Ray ... Intravenous fluids ...D. MEDICAL SCREENING EXAM (MSE): A process that determines whether or not and emergent medical condition exists. All patients presenting to the ED for care are required to have an MSE by an ED provider (Physician, Nurse Practitioner (NP), or Physician's Assistant (PA). POLICY: ... B. All patients presenting to the ED for treatment will be assessed by a Registered Nurse (RN) to determine the urgency of the patient's condition and will be assigned a triage/acuity level based on the ESI system...PROCEDURE: ...The RN will initially obtain and document objective information and assessment to include: Presenting complaint /symptoms ...Vital Signs ...Pain assessment utilizing the appropriate pain scale ... The triage staff may initiate treatment as indicated ...diagnostic studies for appropriate patients utilizing standardized procedures. Upon completion of assessment the RN will use the ESI system to assign a triage level...ESI Level 2: Three broad questions are used to determine whether patient meets Level 2 criteria ...1. Is this a high risk situation ...patient who presents with symptoms suggestive of a condition requiring time-sensitive treatment ...a patient who has a potential life or organ threat ...active chest pain ...3. Is the patient in severe pain ...determined by observation and/or self-reported pain rating of 7 or higher on a scale of 0-10 ...ESI level 2 patients are high priority, and generally, placement and treatment should be initiated rapidly ... ESI Level 3 requires 2 or more resources... Level 3: Conditions that could pose a potential threat to patient's health requiring timely emergency intervention and would benefit from evaluation and/or treatment...."


The hospital policy and procedure titled "Standardized Procedures in the Emergency Department: Initial Treatment and Diagnostics" dated 2/14/18, indicated, "...PURPOSE: To provide for the ordering of diagnostic studies and initial treatment prior to exam of the patient by a physician/NP/PA ...to facilitate diagnosis, expedite flow, improve care for the patient ... POLICY: In lieu of physician's orders, the RN who is authorized to perform Standardized Procedures (SP) shall implement the specific SP independent of physician supervision under the following circumstances: a. When a patient is registered at MMC Emergency Department (ED), b. When a patient is initially assessed by a triage or treatment nurse and the provider is not readily available, c. When a patient presents with the chief complaints as outlined in the SP... 4.Chest Pain ...c. Obtain nursing history and physical exam ...vital signs ...use PQRST mnemonic to gather information about chest pain (Provoke, Quality, Radiation, Severity, Time), identify other symptoms including dyspnea, nausea and vomiting, diaphoresis ...obtain brief history and evaluate risk factors for cardiac disease ...current medications ...d. EKG Studies- Stat 12 lead EKG ...present to physician immediately to rule out ST elevation Myocardial Infarction (STEMI)...If the initial EKG is not diagnostic ...serial EKGs initially at 5 to 10 minute intervals could be performed to detect the potential for development of ST-segment elevation or depression ...e. Lab Studies to be initiated for age 35 years or older or for any STEMI patient: Troponin I, CBC, CMP, draw "rainbow" and send to lab ...radiographic studies to be initiated in patients 35 years of age or older or for any STEMI: chest x-ray, 2-view... f. Treatment in the treatment area: place on cardiac monitor and monitor cardiac rhythm and rate, blood pressure, continuous pulse oximetry...IV access: IV normal saline or saline lock...For STEMI: two large bore IV's ...Medication: Oxygen as needed to keep oxygen saturation> 95% or for STEMI...Aspirin 324 mg PO (chewed) x 1 dose for patients 35 years of age or older...For appropriate patient, consult with physician and obtain order for Nitroglycerin 0.4 mg SL up to every 5 minutes x 3 doses as needed for chest pain, Morphine 2 to 4 mg IV as needed for chest pain ...14. Psychiatric Complaints ...used for the patient presenting with suicidal or homicidal ideations, or other psychiatric complaint where the nurse anticipates a mental health consult ...Obtain nursing history and physical exam: vital signs ...focused assessment and HPI ...Brief History ...current medications ...Screening and Medical Clearance Diagnostic Studies: Urine drugs of abuse screen, alcohol, salicylate level, acetaminophen level, CBC, CMP, 12-lead EKG, urine dip and analysis, urine pregnancy test (females age 10-60 years), fingerstick glucose if patient is diabetic...Treatment in treatment area: Obtain IV access ... place on cardiac monitor and monitor cardiac rhythm and rate, blood pressure, continuous pulse oximetry as indicated ...."


The hospital policy and procedure titled "RME (Rapid Medical Evaluation) Guidelines" dated 5/11/16, indicated,"...During periods that RME is staffed, patients that cannot immediately be moved to an ED examination room will be assessed by an ED provider in order to complete the Medical Screening Exam (MSE). Patients will be assessed in order of arrival or as determined by clinical staff or provider...RME is a process in which the patient has a rapid medical examination by a provider. The basic goal of RME is to eliminate barriers and bring patients to providers as quickly as possible upon arrival at the emergency department ...the initial provider evaluation will occur as quickly as possible upon patient arrival and appropriate orders will be initiated ...Patient presents to RN Greeter who will obtain chief complaint ...the greeter RN will determine if a life threatening or time-sensitive condition exists and ...will take appropriate action ...standardized procedures may be initiated during the RME process in order to expedite care ...immediate bedding will be utilized when beds available in the ED ...."

Based on observation, interview, and record review, all medical records were not accessible, particularly during an outage of the electronic health record (E.H.R.) system which lasted two days during the week of 5/14/18.

The federal complaint validation survey began at 10 AM on 5/14/18. On 5/15/18 in the early morning hours at or around 12:30 am, the facility's access to their E.H.R. unexpectedly shut down. The entire hospital system network of their E.H.R. was declared to be out of service from 5/15/18, including the hospital's e-mail communication. The facility's alert code known as "Code Lime" was initiated immediately for downtime processes to be initiated when the E.H.R. system was down.

The inpatient nursing stations on the second floor were observed on 5/15/18. Back up access of the E.H.R. on inpatient nursing stations was to be from a single Business Continuity Access (BCA) device located at each nursing station on patient care floors. This computer terminal provided a "read only" viewing of patient medical records with medical record data which had been backed up through 5/14/18.

An observation of the Cardiac Telemetry nursing station located on the third floor was conducted on 5/15/18. A view of the patient status board which listed patients currently being treated as inpatients on the nursing unit numbered approximately 30 inpatients. The sole BCA was not accessible to nurses due to a physician using the room, with the door closed to the room where the BCA was located. Downtime forms, paper-based documents to be able to record patient care by manual process, were readily available on the nursing unit counter. There was no accessibility to advance directive information or code status of patients without the BCA. There was no ability of care providers to verify past patient care documentation including documentation of laboratory and radiology results, prior history and physical examinations, recent surgery or procedures, history of medications/prescriptions, allergies, and patient wishes in advance directives.

In an interview with the head nurse in the Cardiac Telemetry unit regarding determination of a patient's code status while the E.H.R. system was down, she stated that it could not be determined unless specified on the patient identification bracelet at admission or on the status board in the patient room. Access to the specific details of an Advance Directive for each patient, if available and which could change during a patient stay, was not possible while the E.H.R. system was down.

A review of the "Sutter E.H.R. Downtime and Recovery Policy" listed the purposes for recovery of medical records in "patient registration, ordering/providing diagnostics, documenting care, reporting of results, providing treatment and other patient care".

A review of the Advance Health Care Directive form provided on 5/14/18 provided instruction that patients be able to specify alternative individuals to make health care decisions, direct the provision or artificial nutrition or hydration and other patient wishes regarding medical treatment.

A review of the "HIM Specific Disaster Plan" dated as 11/5/2015 when last revised & approved, had no mention of a Code Lime procedure to follow in " Emergency Management P&P" to provide back up medical record information in clinical care areas.

Upon observation there was no BCA in the HIM department, and on 5/16/18, access to the E.H.R. fluctuated or was not accessible by HIM1.

A review of the "Memorial Medical Center Quality Statistics" for the past year from May 2017 to April 2018 showed an average 63% completion of "ED Prov Note Completion" (Emergency Department Provider Note Completion) compared to a targeted standard of 95% completion. The provider documentation in the Emergency Room is largely provided by scribes (non-physician medical personnel who transcribe the medical information), as stated in an interview with the ED Informatics nurse on 5/14/18. Accuracy of the content of the ED medical record documentation was validated only with the attestation (signature indicating the information is complete and accurate) of an attending physician.

Note/s:
Based upon interview and record review, medical records were not completed in a timely manner, particularly for Emergency Department records and verbal order authentication within 48 hours. Also based upon observation, interview and record review, the downtime backup system did not provide care providers access to a complete medical record.

The report submitted for the quarterly Quality and Safety Committee was requested and provided on 5/14/18. A review of the report's monthly tracking in the "Memorial Medical Center Quality Statistics" report showed "ED Prov. Note Completion" per month ranging from 58% to 69% completion for March 2017 - April 2018, with a standard target goal of 95%. The "Verb. Order Compliance" per month showed 79% - 84% performance for March 2017 - April, with a standard target goal of 95%.

A review of the "Provider Suspension for Chart Deficiencies" report printed on 5/14/18 showed there were 34 providers on suspension.

In an interview with the HIM Director (HIM1) on 5/15/18, it was stated that the high number of chart deficiencies was raised to the quarterly Quality and Safety Committee, and in the April 2018 Medical Executive Committee.

In an interview with the Medical Staff Specialist (MSC) on 5/16/18, it was stated that she was "not informed of the type of (medical record) deficiency" nor "know how HIM communicates to the (medical staff) department". She stated that notification of physicians should be by multiple means and "some physicians do not use Sutter's email", estimating 50% of the local active physicians do not utilize the Sutter email address.

A review of the "Administrative Completion of Deficiencies Policy" had a process for closure of the incomplete medical records yet the "Provider Suspension for Chart Deficiencies" showed medical record deficiency suspensions for 6 different providers dating back to 6/20/15, 1/14/16, 6/26/16, and 11/2/17 (3).

In a review of the "Sutter E.H.R. Downtime and Recovery Policy" the policy was that the "process shall ensure the legal health record is complete, accurate and reflective of current patient information both during and after downtime".

During the E.H.R. downtime, it was observed that care providers did not have full access to complete medical records in all nursing units with only one BCA per nursing unit.

Based upon interview and record review, there was an excessive number medical record deficiencies for authentication of verbal orders within 48 hours for the last twelve months, reported as an 82% Verbal Order compliance on the facility Quality Statistics.

Verbal orders are care provider orders for medications, treatments, interventions or other patient care that are transmitted as oral, spoken communications between senders and receivers, usually physician to nurse by voice or by telephone. The time frame to sign the order is 48 hours according to federal and state regulations so that the care provider can review the orders and assure that the information that is entered is correct, and to reduce the potential risk of an adverse event with medication orders.

The facility report of medical record deficiencies from May 2017 to April 2018 was requested and provided on 5/14/18, and showed a range of 79% to 84 % per month for verbal orders signed within 48 hours. The stated target goal for the facility was 95% authentication (review and signature) within 48 hours.

During an interview with HIM1 on 5/15/18, she stated the issue of unsigned verbal orders has been raised in the past twelve months to the hospital's Quality & Safety Committee.

In an interview with the Medical Staff Coordinator (MSC) conducted on 5/15/18, she stated there has been discussion on unsigned verbal orders yet the issue "has never been brought to a (medical staff) department meeting" that she had ever attended.

A review of the "Administrative Sign-Off of Verbal Orders" indicated a facility policy was available to "close" unsigned verbal orders although the policy stated "Verbal orders shall be signed within the time frame required by regulatory agencies, hospital policy and the Medical Staff Rules and Regulations", stated to be within 48 hours of the verbal order.

In a review of the "Delinquencies by Provider with Patient Detail" report showed eighteen pages of medical record deficiencies, primarily for unsigned verbal orders.

Based on observation, staff interviews, clinical record and administrative document review, the hospital failed to meet emergency needs of patients in accordance with the hospital's policies and procedures when:

1.. Patient 1 presented to the Emergency Department (ED) on 3/28/18 at 5:40 a.m. with the chief complaint of Chest Pain (pain level of 8 on a scale 0 to 10) and history of high blood pressure and the first contact with the qualified medical professional (QMP) was at 8:04 a.m. The triage Registered Nurse (RN 1) assessed Patient 1 and obtained the blood pressure of 186/120, determined the ESI as 3, initiated but did not completely implement the Chest Pain standardized protocol and did not prioritize Patient 1 to be seen by the QMP and had Patient 1 wait in the lobby. (Refer to A 392)

2. Patient 24 presented to the ED on 2/6/18 at 10:44 a.m. with the chief complaint of Chest Pain (pain level of 10 on a scale of 0 to 10). The triage Registered Nurse (RN 9) assessed Patient 24 and determined the ESI as 3, initiated but did not completely implement the Chest Pain standardized protocol and did not prioritize Patient 24 to be seen by the QMP and had Patient 24 wait in the lobby. The first contact with a QMP for the MSE was on 2/6/18 at 3:02 p.m. (almost 4 ½ hours after walking into the ED). (Refer to A 392)

3. Patient 13 presented to the ED via ambulance on 1/25/18 at 10:13 a.m. with the chief complaint of suicidal ideation with depression. Patient 1 was triaged and prioritized with an ESI of 2 and placed in Hallway 7 bed. The standardized protocol for psychiatric evaluation was initiated but was not fully implemented. (Refer to A 392)

4. Policies and procedures for the care of patients in the ED were not evaluated and updated on an on-going basis to ensure standardized procedures were current and being fully implemented by nursing staff. (refer to A 1104)

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality healthcare in a safe environment.

Based on interview, clinical record, and administrative document review, the hospital failed to ensure policies and procedures for care of emergency department patients were current and fully implemented by nursing staff.

1. Patient 1 presented to the Emergency Department (ED) on 3/28/18 at 5:40 a.m. with the chief complaint of Chest Pain (pain level of 8 on a scale 0 to 10) and history of high blood pressure. The triage Registered Nurse (RN 1) assessed Patient 1, obtained her blood pressure of 186/120 (normal range 120/80-140/90), and determined the Emergency Severity Index (ESI: a five-level triage system that categorizes emergency department patients by evaluating both patient acuity and resources [tests, procedures, or treatments likely to be utilized in order to determine the disposition of a patient]) as Level 3. RN 1 initiated, but did not completely implement the Chest Pain standardized procedure (SP), did not prioritize Patient 1 to be seen by a provider (Physician, Physician's Assistant, Nurse Practitioner), did not prioritize obtaining the blood samples for the lab tests ordered, and had Patient 1 wait in the lobby.

2. Patient 24 presented to the ED on 2/6/18 at 10:44 a.m. with the chief complaint of Chest Pain (pain level of 10 on a scale of 0 to 10). The triage Registered Nurse (RN 9) assessed Patient 24 and determined the ESI as Level 3, initiated but did not completely implement the Chest Pain SP, did not prioritize Patient 24 to be seen by a provider, and had Patient 24 wait in the lobby.

3. Patient 13 presented to the ED via ambulance on 1/25/18 at 10:13 a.m. with the chief complaint of "suicidal ideation [SI] [thinking about or planning suicide], and depression [A mental health disorder causing persistent feelings of sadness that affect a person's daily life]." Patient 13 was triaged and prioritized with an ESI of 2 and placed in Hallway 7 bed. The SP for psychiatric complaints was initiated but not fully implemented.

These failures resulted in a delay in evaluation and treatment of Patients 1,13, and 24 by a provider.

Findings:

1. Review of Patient 1's clinical record indicated:
On 3/28/18 at 5:40 a.m., Patient 1, a 41 year old female, arrived via private car to the hospital's Emergency Department (ED) and checked in with RN 1. Patient 1 provided RN 1 the chief complaint that she had been experiencing chest pain for three days described as burning, tightness and intermittent. Patient 1 described her current pain level as 8 on a scale of 0 to 10. RN 1 assigned Patient 1 an ESI of 3.

5:43 a.m.: RN 1 initiated orders from the Chest Pain Standardized Procedure (SP: a protocol for RNs which allows for ordering diagnostic studies and providing initial treatment in specific situations prior to a patient being examined by a provider [physician/physician's assistant/nurse practitioner]) as follows: Blood tests for Troponin I (a protein released when the heart muscle is damaged), CBC (complete blood count), Metabolic Panel (Test measuring blood sugar levels, electrolyte and fluid balance, kidney function, and liver function), 12-lead Electrocardiogram (EKG or ECG-looks at electrical activity in the heart), Chest X-ray, and a urine pregnancy test. RN 1 did not initiate orders for cardiac monitoring, or placing an intravenous line (IV-inside the vein). RN 1 did not perform a focused assessment, obtain a history to identify cardiac risk factors, describe characteristics of pain, or identify all medications taken.

5:45 a.m.: RN 1 obtained the following vital signs from Patient 1: temperature of 96.8 degrees Fahrenheit, a pulse of 75 beats per minute (bpm), respiratory rate of 20, oxygen saturation of 98 percent, and a blood pressure (BP) of 186/120. RN 1 documented next to the blood pressure value: "history of hypertension (high blood pressure), took meds prior to arrival".

5:53a.m.- 6:00 a.m.: Chest x-ray completed.

6:02 a.m.:12-lead EKG completed.

6:07 a.m.: An ED Medical Doctor (MD 1) reviewed the EKG, initialed and marked on the EKG form "no STEMI" (ST elevation myocardial infarction [heart attack]). The EKG automated interpretation was "left axis deviation, ventricular hypertrophy with QRS widening and repolarization abnormality, inferior infarct, age undetermined, anterolateral infarct age undetermined, abnormal ECG [EKG]."

After the EKG was completed, Patient 1 waited in the lobby.

7:09 a.m.: Patient 1 was in Rapid Medical Evaluation (RME) room 2 with RN 2.

7:42 a.m.: Blood samples sent to the lab by RN 2.

7:45 a.m.: BP 128/93 and pulse of 109 bpm.

8:00 a.m.: BP 128/108.

8:02 a.m.: Patient 1 is at the registration desk.

8:04 a.m.: Physician Assistant (PA) 1's note indicated he reviewed Patient 1's record, obtained a brief history, and performed a limited exam. PA 1 documented "...Patient 1 has a history of hypertension ... presents to the ED for evaluation of intermittent left sided chest pain for three days described as burning and tightness with shortness of breath on inspiration (breathing in). Reports episodes of chest pain this morning that lasted approximately 1.5 hours. Reports being awoken by chest pain...." PA 1 discussed the EKG results with MD 2 and documented: "no STEMI but concerning findings" and a plan to place Patient 1 in a "bed in the back" (bed in the ED core).

8:10 a.m.: Registration completed. The record does not indicate Patient 1 was observed again after registration.

8:11 a.m.: RN's note indicated the plan to put Patient 1 in a bed in the back.

8:38 a.m.: Critical lab result for troponin was reported to PA 1; the troponin level was 3.3 (normal range is 0.00 to 0.05).

8:42 a.m.: RN 2 documented "...attempted to take to room in main ED, patient not found, lobby, bathrooms; multiple attempts to locate patient unsuccessful. Called phone number on chart, no answer at this time ... PA aware; charge nurse aware."

8:45 a.m.: RN 2 documented "...Attempted to find patient in lobby X 2; unable to find patient or boyfriend."

10:15 a.m.: Record indicated Patient 1 as discharged.

12:49 p.m.: Patient 1 arrived in ED. Triage RN (RN 11) assigned Patient 1 an ESI of 2. BP 136/86.

12:53 p.m.: To Room 37 in ED core.

12:59 p.m.: Patient 1 placed on cardiac monitor, non-invasive blood pressure monitor and continuous pulse oximetry.

1:01 p.m.: EKG completed. Automated interpretation noted as "Sinus tachycardia (rapid heart beat), T-wave abnormality, Abnormal ECG [EKG]". Pain assessment was 3 out of 10. Chest X-ray was done.

1:18 p.m.: MD 2 obtained Patient 1's history of methamphetamine use, last use yesterday. Also noted family history of cardiac disease; father had MI at 40 y/o.

From 1:19 p.m. until 2:45 p.m. the care of Patient 1 included blood draw for lab tests, placement of intravenous access and administration of medications including Aspirin, Ativan, Clonidine, nitroglycerin, diltiazem, potassium chloride and heparin (medications that are part of the protocol for patients having a heart attack).

2:05 p.m.: Critical lab value of Troponin 8.55 (range 0.00-005) was reported, as well as Pro-Brain Natriuretic Peptide (PROBNP- a protein present in heart failure) of 1,270 pg/ml (Normal range: 0-450 pg/ml)

2:45 p.m.: MD 2 indicated decision to admit. Diagnosis: Non-STEMI (non-ST elevated myocardial infarction).

4:04 p.m.: Patient 1 was admitted to the telemetry (unit where patients hearts are continuously monitored) unit on the second floor.

2. Review of Patient 24's clinical record indicated:

On 2/6/18 at 10:44 a.m., Patient 24, a 90 year old non-English speaking female, arrived by car to the hospital's ED and checked in with triage nurse (RN 9). Patient 24's chief complaint was documented, "patient came in with chest pain that began last night; patient also states cough with sputum production for the past 2 months." Patient 24's chest pain level documented at 10 on a scale of 0-10. Blood Pressure at triage was 133/63, pulse 66 bpm and Temp 36.4 degrees Celsius. Oxygen saturation 95 %.

10:47 a.m.: Triage completed. Patient 24 assigned an ESI of 3. After triage was completed, Patient 24 waited in the lobby.

10:49 a.m.: Standardized procedure for chest pain initiated and orders placed for laboratory tests, chest x-ray, and EKG. The record did not indicate the use of a cardiac monitor or placement of an IV.

10:56 a.m.: EKG completed. Screening by ED physician indicated no STEMI (ST elevation myocardial infarction).

11:07 a.m.: Blood samples obtained and sent to the lab.

11:40 a.m.: Chest x-ray completed. Results within normal limits for patient. Patient to wait in lobby.

11:41 a.m. to 2:29 p.m. - There is no documentation of observation or location of Patient 24 during this time. No indication vital signs obtained or cardiac monitoring done.

2:29 p.m.: Patient 24 was taken to the RME (Rapid Medical Evaluation) room to have a Medical Screening Exam (MSE: an exam to determine if an emergency medical condition exists) performed. Patient 24's chest pain level was a 6 on a scale of 0-10. Patient was alert and had a frequent cough. Nurses notes indicate "Patient [Patient 24] c/o chest pain on and off over the past couple of months. Patient states she had chest pain all night and continued today that was worse than normal. Patient has had a cough for the last three weeks."

3:02 p.m.: MSE performed by MD 3.

3:12 p.m.: Patient 24 received an albuterol breathing treatment (medication used to prevent and treat breathing difficulties, shortness of breath and coughing). Oxygen saturation 96%, pulse 65, respiratory rate 20/minute. No blood pressure value recorded. Patient moved to internal waiting room.

3:21 p.m.: Results of lab test D Dimer (blood sample that measures whether or not there are blood clots present in the blood) returned elevated at 597 (normal range less than 250).

3:39 p.m.: Chest Computed Tomography (a diagnostic imaging test to examine organs, soft tissue, blood vessels, and bones) with contrast was ordered by MD 3.

4:28 p.m.: Final result of the EKG performed at 10:51 a.m. was entered into the ED record. Diagnosis: "Atrial fibrillation [an irregular heart rhythm occurring when the top chambers of the heart beat out of coordination with the lower chambers] with a competing junctional pacemaker, left anterior fascicular block [blockage of one of the electrical branches that delivers electrical signals to a part of the left ventricle, one of two chambers in the heart], abnormal ECG. When compared with ECG of June 2017, atrial fibrillation has replaced sinus rhythm (normal heart rhythm)." The record does not indicate whether an ED physician was aware of the EKG results or discussed the findings with Patient 24.

4:41 p.m.: RN 6 indicated Patient 24 wanted to go home prior to the Chest CT exam and RN 6 informed MD 3.

5:43 p.m.: RN 6 indicated Patient 24 was upset at wait times, refused CT of the chest and requested to leave Against Medical Advice (AMA). MD 3 was notified via phone; did not speak with Patient 24 or family. Patient 24 signed AMA form using language line interpreter # 183500 and Pt 24 left with her son. RN 6 indicated instructions were not provided to Patient 24 prior to her leaving the hospital.

The record did not indicate Patient 24's vital signs were obtained after 3:12 p.m., a chest pain level assessed after 2:35 p.m., or use of a cardiac monitor during Patient 24's ED visit.

3. Review of Patient 13's clinical record indicated:

On 1/25/18 at 10:13 a.m., Patient 13 a 28 year old male brought in by ambulance (BIBA) to the hospital's ED with a chief complaint "suicidal ideation and depression."

10:19 a.m.: Triage completed with Patient 13 assigned an ESI of 2, and placed in hallway bed 7. Triage nurse indicated, "+ Suicidal Ideation [BIBA from home for feeling depressed, voluntary 5150 hold per EMS. No plans of hurting himself at this time per pt.]"

10:20 a.m.: Nursing assessment indicated Patient 13 was alert and oriented with a depressed mood.

10:43 a.m.: Vitals signs obtained were within normal limits.

10:48 a.m.: Orders initiated per the Standardized Procedure for psychiatric complaints, including a metabolic panel, complete blood count (CBC), urinalysis (UA), and blood tests for alcohol, salicylate (aspirin), and acetaminophen (Tylenol). Urine drug screen was not obtained. The record does not indicate an intravenous line (IV) was ordered or a cardiac monitor.

10:54 a.m.: A chart entry indicated a physician was assigned to Patient 13, however the record does not indicate Patient 13 was seen by a provider.

10:55 a.m.: Urine specimen obtained. No further documentation of contact or observation of Patient 13 within the ED.

11:22 a.m.: RN 7 indicated, "...Pt [Patient 13] unable to find in bed. Public safety informed. Pt not in lobby...Charge Nurse informed and aware...."

11:26 a.m.: RN 8 indicated,"...Attempted to call pt's cell phone listed...unable to leave voicemail... [local town] PD contacted to notify them of patient elopement...." No documentation of the provider being notified. PT 13 discharged in computer and given the disposition of elopement.

On 5/16/18 at 11 a.m., during a concurrent interview and clinical record review, RN 8 stated she was working on 1/25/18 as charge nurse when Patient 13 was in the ED. RN 8 stated a staff nurse informed her Patient 13 eloped, and RN 8 contacted the police department. RN 8 did not know if a "sitter" (a staff person assigned to be physically present to observe patient at all times) was requested for Patient 13; the record did not indicate that a sitter was present. RN 8 stated if a sitter is needed, an ED tech can assume this role, or the staff call the house supervisor to request help.

On 5/16/18 at 11:05 a.m., during a concurrent interview and record review, RN 7 stated she was the triage RN for Patient 13 on 1/25/18. RN 7 recalled that Patient 13 was BIBA after calling 9-1-1 because he (Patient 13) stated he wanted to hurt himself. RN 7 stated when Patient 13 arrived to the ED, her assessment was Patient 13 did not have a "plan" to hurt himself. RN 7 assigned Patient 13 an ESI of 2. RN 7 stated she was told no other beds were available so Patient 13 was put in hallway bed 7. RN 7 stated she was familiar with the standardized procedures and they usually do follow them to help expedite the care. RN 7 stated she did not initiate all of the orders in the standardized procedure though because "they can pick and choose" which ones to implement. RN 7 stated she did not see Patient 13 leave the department; she found out he was gone when staff from the lab asked where Patient 13 was. RN 7 stated as far as she knows no staff in the ED saw Patient 13 leave. When asked what safety measures were implemented for Patient 13, RN 7 stated "He needed a sitter to be with him." RN 7 stated Patient 13 had been in ED "less than an hour" and they "eventually would get him a sitter." RN 7 stated she notified the physician when Patient 13 left; she just did not document that.

On 5/14/18 at 10:15 a.m. during an observation in the ED triage area and lobby (external waiting room), approximately 15 patients wearing identification bands on their wrists sat in chairs in the lobby. Some of the patients were observed with disposable blood pressure cuffs wrapped around their upper arms; no saline locks (IV catheter left in vein to provide access for administration of fluids and medications). None of the patients appeared to be in any distress. A female patient was observed in a wheelchair at the triage desk accompanied by a friend. The triage RN greeted the patient and obtained the chief complaint of heart palpitations and chest pain/discomfort. The triage RN took the patient's vital signs and informed the patient her heart rate was elevated. The patient stated she has atrial fibrillation The triage RN called the charge nurse immediately to inform her about this patient's condition and symptoms. Approximately two minutes later, the charge nurse arrived at the triage desk and transferred the patient back to the RME (Rapid Medical Evaluation) area to be seen by a provider.

On 5/14/18 at 10:25 a.m., during a concurrent observation and interview in the ED triage area and lobby, the ED Manager (EDM) stated they had been working hard to make changes in the ED in response to the issues previously identified concerning Patient 1's care. The EDM explained the recent changes made: The hospital's policies and procedures related to ED care had "just been revised this past week." The EDM stated the D-Pod (an area in the ED core containing eight monitored beds) has been re-opened which means more patients can be put in ED beds, and fewer patients will have to wait out in the lobby in various stages of the evaluation process.The EDM stated D-Pod is now open Mondays, Tuesdays, and Thursdays. The EDM stated these days were chosen based on evaluating the patient volume over time. The EDM stated she obtained approval for additional RN positions with the goal being to keep D-Pod open all of the time. The EDM stated all ED nursing staff have been re-educated on the use of standardized procedures. The expectation is all orders in the appropriate SP will be initiated if the estimated wait time prior to the patient seeing a provider exceeds 30 minutes. The EDM stated all staff have been re-educated that if there is not a phlebotomist assigned to the ED to draw blood for lab tests, they can call the lab for assistance or draw the blood sample themselves; they are not to delay obtaining the blood sample. The EDM stated ED nursing staff were also re-educated to the fact that there is always a provider in the ED 24 hours a day. If the provider is not in Triage or the RME area, they will be in the ED core. The EDM stated another change they have made is patients who have been triaged and assigned an ESI Level 2, will not be put in the lobby except on rare occasions. All patients with an ESI Level 2, and patients with abnormal vital signs will be escalated by the triage nurse in order to be seen by the provider in a timely manner. The EDM stated they have changed the responsibilities of a couple of the RNs who were previously assigned to help out in the ED core and now they are responsible for checking on the patients in the lobby who are waiting to see a provider, or have lab tests or x-rays done, etc. The EDM stated another change they have implemented is putting a registration clerk in the ED so the patients will not have to leave the area to register any longer and there is less chance they will leave altogether.

On 5/15/18 at 2:10 p.m. during a concurrent interview and observation of the ED lobby, none of the patients waiting in the lobby were observed to have saline locks. The charge nurse (RN 13) stated patients with "saline locks are not allowed in the lobby...this practice changed when the policy changed...."

On 5/15/18 at 2:18 p.m., during a concurrent inerview and observation in the ED, RN 14 stated no high acuity patients are allowed to wait in the lobby, must be in the RME area. RN 14 stated, "A week ago this was changed." RN 14 stated patients with chest pain are not put in the lobby.

The hospital policy and procedure titled, "Triage Policy" dated 5/14/16, indicated, "...DEFINITION: A. TRIAGE: is a process by which patients who present to the Emergency Department (ED) are assessed and prioritized for a Medical Screening Exam. Triage determines the time order sequence in which a patient should be seen through assessment of severity of complaint using the Emergency Severity Index (ESI) five-level triage system. B. ESI: A five-level triage system that categorizes emergency department patients by evaluating both patient acuity and resources... C. RESOURCE: a diagnostic test, procedure and therapeutic treatment that is likely to be utilized in order to make a disposition of the patient ...Labs, EKG, X-Ray ... Intravenous fluids ...D. MEDICAL SCREENING EXAM (MSE): A process that determines whether or not and emergent medical condition exists. All patients presenting to the ED for care are required to have an MSE by an ED provider (Physician, Nurse Practitioner (NP), or Physician's Assistant (PA). POLICY: ... B. All patients presenting to the ED for treatment will be assessed by a Registered Nurse (RN) to determine the urgency of the patient's condition and will be assigned a triage/acuity level based on the ESI system...PROCEDURE: ...The RN will initially obtain and document objective information and assessment to include: Presenting complaint /symptoms ...Vital Signs ...Pain assessment utilizing the appropriate pain scale ... The triage staff may initiate treatment as indicated ...diagnostic studies for appropriate patients utilizing standardized procedures. Upon completion of assessment the RN will use the ESI system to assign a triage level...ESI Level 2: Three broad questions are used to determine whether patient meets Level 2 criteria ...1. Is this a high risk situation ...patient who presents with symptoms suggestive of a condition requiring time-sensitive treatment ...a patient who has a potential life or organ threat ...active chest pain ...3. Is the patient in severe pain ...determined by observation and/or self-reported pain rating of 7 or higher on a scale of 0-10 ...ESI level 2 patients are high priority, and generally, placement and treatment should be initiated rapidly ... ESI Level 3 requires 2 or more resources... Level 3: Conditions that could pose a potential threat to patient's health requiring timely emergency intervention and would benefit from evaluation and/or treatment...."


The hospital policy and procedure titled "Standardized Procedures in the Emergency Department: Initial Treatment and Diagnostics" dated 2/14/18, indicated, "...PURPOSE: To provide for the ordering of diagnostic studies and initial treatment prior to exam of the patient by a physician/NP/PA ...to facilitate diagnosis, expedite flow, improve care for the patient ... POLICY: In lieu of physician's orders, the RN who is authorized to perform Standardized Procedures (SP) shall implement the specific SP independent of physician supervision under the following circumstances: a. When a patient is registered at MMC Emergency Department (ED), b. When a patient is initially assessed by a triage or treatment nurse and the provider is not readily available, c. When a patient presents with the chief complaints as outlined in the SP... 4.Chest Pain ...c. Obtain nursing history and physical exam ...vital signs ...use PQRST mnemonic to gather information about chest pain (Provoke, Quality, Radiation, Severity, Time), identify other symptoms including dyspnea, nausea and vomiting, diaphoresis ...obtain brief history and evaluate risk factors for cardiac disease ...current medications ...d. EKG Studies- Stat 12 lead EKG ...present to physician immediately to rule out ST elevation Myocardial Infarction (STEMI)...If the initial EKG is not diagnostic ...serial EKGs initially at 5 to 10 minute intervals could be performed to detect the potential for development of ST-segment elevation or depression ...e. Lab Studies to be initiated for age 35 years or older or for any STEMI patient: Troponin I, CBC, CMP, draw "rainbow" and send to lab ...radiographic studies to be initiated in patients 35 years of age or older or for any STEMI: chest x-ray, 2-view... f. Treatment in the treatment area: place on cardiac monitor and monitor cardiac rhythm and rate, blood pressure, continuous pulse oximetry...IV access: IV normal saline or saline lock...For STEMI: two large bore IV's ...Medication: Oxygen as needed to keep oxygen saturation> 95% or for STEMI...Aspirin 324 mg PO (chewed) x 1 dose for patients 35 years of age or older...For appropriate patient, consult with physician and obtain order for Nitroglycerin 0.4 mg SL up to every 5 minutes x 3 doses as needed for chest pain, Morphine 2 to 4 mg IV as needed for chest pain ...14. Psychiatric Complaints ...used for the patient presenting with suicidal or homicidal ideations, or other psychiatric complaint where the nurse anticipates a mental health consult ...Obtain nursing history and physical exam: vital signs ...focused assessment and HPI ...Brief History ...current medications ...Screening and Medical Clearance Diagnostic Studies: Urine drugs of abuse screen, alcohol, salicylate level, acetaminophen level, CBC, CMP, 12-lead EKG, urine dip and analysis, urine pregnancy test (females age 10-60 years), fingerstick glucose if patient is diabetic...Treatment in treatment area: Obtain IV access ... place on cardiac monitor and monitor cardiac rhythm and rate, blood pressure, continuous pulse oximetry as indicated ...."


The hospital policy and procedure titled "RME (Rapid Medical Evaluation) Guidelines" dated 5/11/16, indicated,"...During periods that RME is staffed, patients that cannot immediately be moved to an ED examination room will be assessed by an ED provider in order to complete the Medical Screening Exam (MSE). Patients will be assessed in order of arrival or as determined by clinical staff or provider...RME is a process in which the patient has a rapid medical examination by a provider. The basic goal of RME is to eliminate barriers and bring patients to providers as quickly as possible upon arrival at the emergency department ...the initial provider evaluation will occur as quickly as possible upon patient arrival and appropriate orders will be initiated ...Patient presents to RN Greeter who will obtain chief complaint ...the greeter RN will determine if a life threatening or time-sensitive condition exists and ...will take appropriate action ...standardized procedures may be initiated during the RME process in order to expedite care ...immediate bedding will be utilized when beds available in the ED ...."