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Based on interview and record review, the governing body failed to ensure the services provided by the Emergency Department (ED) medical staff were provided in accordance with the goals and objectives set forth by the facility. This failed practice resulted in known and continued long waits for patients presenting for care, and the potential for patient harm or death.

Findings:

The Emergency Department Services Agreement (contract between the facility and the ED physician group) was reviewed on February 1, 2017. The contract indicated the following:

1. Exhibit C, Page 2 - The Medical Director would:

a. Conduct quality improvement activities for the Department;

b. Participate in and coordinate the (facility) utilization management and quality management activities in an effort to provide adequate and safe services in the department and achieve a high level of patient service and care with efficiency and economy in respect to medical services performed by the department;

c. Coordinate and participate in the (facility) quality assurance activities to assure the adequacy and safety of services rendered in the department; and,

d. Oversee a quality assessment and performance program to monitor the appropriateness of department procedures and submit findings as a part of the overall quality assessment and performance improvement plan of the (facility).

2. Exhibit F - Performance Metrics to be measured included:

a. Door to doctor time;

b. Length of stay;

c. Left without being seen; and,

d. Patient satisfaction scores.

There were no goals or targets included in the metrics.

During an interview with the Director of Quality (DQ) on February 1, 2017, at 3 p.m., the DQ stated the facility was aware that the ED physician contract included metrics, but did not have any actual expectations to hold the physician group accountable to. The DQ stated that would be discussed during the next contract renewal.

The 2016 Emergency Medicine Department meeting minutes were reviewed on February 1, 2017. The minutes indicated the following:

a. January 12, 2016, the committee discussed the possibility of ED expansion. No quality or performance data was presented. No patient satisfaction scores were discussed;

b. March 8, 2016, the committee discussed ED metrics regarding what was causing delays in the "throughput" times (time patient is in the ED from arrival to departure) and in the number of patients who left without being seen. Areas identified included lab turnaround times, radiology turnaround times, EKG turnaround times, and lack of inpatient beds. The plan was to work with quality to, "explore," these areas. There was no discussion regarding targets, actual quality or performance data, or specific plans to improve the areas causing delay in patient "throughput";

c. May 10, 2016, No quality or performance data was presented. No patient satisfaction scores were discussed. The policy titled, "Emergency Department Surge/Decompression," was tabled;

d. June 14, 2016, No quality or performance data was presented. No patient satisfaction scores were discussed. The policy titled, "Emergency Department Surge/Decompression," was tabled;

e. August 9, 2016, No quality or performance data was presented. No patient satisfaction scores were discussed; and,

f. December 15, 2016, No quality or performance data was presented. No patient satisfaction scores were discussed.

During an interview with the ED Medical Director (EDMD) on January 31, 2017, at 2:10 p.m., the EDMD stated he was aware of the large number of inpatients being held in the ED. The EDMD stated the facility had tried to collect quality indicators, but they kept having leadership turnover, so projects would get started, then they would stop. The EDMD stated with all of the inpatients they were holding in the ED, the overall "throughput" times would be difficult to improve, as they had, "very few beds," to see ED patients in.

During an interview with the leadership team responsible for ED quality on February 1, 2017, at 9:30 a.m., the Chief of Quality and Patient Safety stated the facility had experienced multiple turnovers in ED leadership that led to data collection starting and stopping. She stated there were plans to begin improving patient flow and processes with the new leadership that was in place.

Based on observation and interview, the facility failed to:

1. Collect data as planned, and use the data to monitor and improve the safety and effectiveness of the services provided in the Emergency Department (ED) (Refer to A273); and,

2. Successfully implement suggested actions recommended by the Performance Improvement Committee (Refer to A283).

The cumulative effect of these systemic problems resulted in failure to ensure the Emergency Department was providing quality care in a safe and effective manner.

33801

Based on interview and record review, the facility failed to collect data as planned, and use the data to monitor and improve the safety and effectiveness of the services provided in the Emergency Department (ED). This failure resulted in the ED continuing to operate with an identified ineffective flow process.

Findings:

On February 1, 2017, the facility's 2016 Quality and Patient Safety Booklet was reviewed.

The Booklet indicated, "...Researchers have linked ED crowding with adverse patient outcomes and impaired access to care. The Institute for Healthcare Improvement demonstrated that regardless of the location, crowding and holding admitted patients is a result of ineffective hospital flow processes...These ineffective flow processes can result in increased costs, compromise the quality of care, and jeopardize the public's faith in healthcare. The need for effective and sustainable solutions are necessary to effectively address patient flow. This requires multidisciplinary collaboration across the care continuum..."

The 2016 Quality and Patient Safety Booklet for the ED identified the following indicators and targets:

1. For Outpatients (discharged, not admitted to the facility):

a. Median time from ED arrival to ED departure time for discharged ED patients. (Goal/National Average = 142 minutes).

Data collection revealed the following results:

April 2016--328 minutes

May 2016--306 minutes

June 2016--345 minutes

July 2016--240 minutes

August 2016--275 minutes

September 2016--256 minutes

The data indicated the facility never met their goal, and no further data was collected after September 2016.

b. Median time from ED arrival to diagnostic evaluation by a qualified personnel. (Goal/National Average = 26 minutes).

Data collection revealed the following results:

April 2016--112 minutes

May 2016--98 minutes

June 2017--101 minutes

July 2016--71 minutes

August 2016--74 minutes

September 2016--47 minutes

The data indicated the facility never met their goal, and no further data was collected after September 2016.

c. Percent of patients who left the ED before being seen. (Goal/California Average = 2%).

Data collection revealed the following results:

April 2016--4.0%

May 2016--2.5%

June 2016--2.5%

July 2016--2.2%

August 2016--1.6%

September 2016--2.2%

No further data was collected after September 2016.

2. For Inpatients (patients admitted to the facility):

a. Mean time from ED arrival to ED departure. (Goal/California Average = 301.5 minutes).

Data collection revealed the following results:

April 2016--655 minutes

May 2016--733 minutes

June 2016--602 minutes

July 2016--616 minutes

August 2016--688 minutes

September 2016--736 minutes

The data indicated the facility never met their goal, and no further data was collected after September 2016.

b. Mean time from decision to admit to departure from ED. (Goal/California Average = 120.5 minutes).

Data collection revealed the following results:

April 2016--455 minutes

May 2016--518 minutes

June 2016--400 minutes

July 2016--401 minutes

August 2016--493 minutes

September 2016--530 minutes

The data indicated the facility never met their goal, and no further data was collected after September 2016.

During an interview with the ED Medical Director (EDMD) on January 31, 2017, at 2:10 p.m., the EDMD stated he was aware of the large number of inpatients being held in the ED. The EDMD stated the facility had tried to collect quality indicators, but they kept having leadership turnover, so projects would get started, then they would stop. The EDMD stated with all of the inpatients they were holding in the ED, the overall "throughput" times would be difficult to improve, as they had, "very few beds," to see ED patients in.

During an interview with the leadership team responsible for ED quality on February 1, 2017, at 9:30 a.m., the Chief of Quality and Patient Safety stated the facility had experienced multiple turnovers in ED leadership that led to data collection starting and stopping. She stated there were plans to begin improving patient flow and processes with the new leadership that was in place.

33801

Based on observation, interview, and record review, the facility failed to successfully implement suggested actions recommended by the Performance Improvement Committee (PIC). These failures resulted in missed opportunities to improve overall "throughput" times (time patient is in the ED from arrival to departure) and quality of care for Emergency Department (ED) patients.

Findings:

1. On February 1, 2017, the facility's Quality and Patient Safety Booklet for 2016 was reviewed. The booklet indicated, "...Researchers have linked ED crowding with adverse patient outcomes and impaired access to care. The Institute for Healthcare Improvement demonstrated that regardless of the location, crowding and holding admitted patients is a result of ineffective hospital flow processes...These ineffective flow processes can result in increased costs, compromise the quality of care, and jeopardize the public's faith in healthcare. The need for effective and sustainable solutions are necessary to effectively address patient flow. This requires multidisciplinary collaboration across the care continuum..."

The following "actions" were suggested by the PIC for the ED:

a. Identify current ED throughput performance by analyzing existing and industry benchmarks and standards;

b. Assess existing throughput flow with an emphasis on the "intake" phase of throughput;

c. Identify inefficiencies and gaps related to throughput processes and performance measures related to best practice and industry standards;

d. Develop an interdisciplinary workgroup to identify opportunity and process deliverables that improve upon ED patient flow and workflow and are measurable efficiencies;

e. With support of stakeholders, implement interim changes related to physical space, processes, workflow, and resources utilization secondary to recommendations made through the ED Performance Improvement workgroup; and,

f. Measure and communicate impact and performance of change.

2. On February 1, 2017, the PIC meeting minutes for the past six months were reviewed.

A. The July 27, 2016, PIC Meeting minutes indicated the following:

a. The goal was to decrease throughput time intervals to National Standards level or better;

b. The biggest problem was, "holds," [inpatients waiting to be transferred to a room], when that was improved they would see an overall improvement in throughput times; and,

c. Planned, "actions," included assessing existing throughput flow, identifying inefficiencies and gaps related to the throughput process, and developing an interdisciplinary workgroup to identify opportunities to improve the ED patient flow.

B. The September 14, 2016, PIC Meeting minutes indicated the following:

a. The overall ED throughput for patients who were transferred from the ED to inpatient beds was 606 minutes (the national average was 302 minutes); and,

b. "For the action plan, ED is trialing a physician provider in the triage area one day per week, attempting to decrease the amount of time between patient arrival and being seen by a healthcare provider".

There was no discussion regarding an update on the actions planned from the previous meeting in July 2016.

C. The October 20, 2016, PIC Meeting minutes indicated, "...Length of stay is still our biggest obstacle..."

There was no discussion regarding an update on the actions planned from the previous meetings.

D. The November 17, 2016, PIC meeting minutes included no report from, or discussion of, the ED throughput time quality data or plan for improvement.

3. On February 1, 2017, the Emergency Medicine Department (EMD) Meeting minutes were reviewed for the past year. The minutes indicated the following:

a. January 12, 2016, the committee discussed the possibility of ED expansion. No quality or performance data was presented. No patient satisfaction scores were discussed;

b. March 8, 2016, the committee discussed ED metrics regarding what was causing delays in the throughput time, and in the number of patients who left without being seen. Areas identified included lab turnaround times, radiology turnaround times, EKG turnaround times, and lack of inpatient beds. The plan was to work with quality to, "explore," these areas. There was no discussion regarding targets, actual quality or performance data, or specific plans to improve the areas causing delay in patient throughput;

c. May 10, 2016, No quality or performance data was presented. No patient satisfaction scores were discussed. The policy titled, "Emergency Department Surge/Decompression," was tabled;

d. June 14, 2016, No quality or performance data was presented. No patient satisfaction scores were discussed. The policy titled, "Emergency Department Surge/Decompression," was tabled;

e. August 9, 2016, No quality or performance data was presented. No patient satisfaction scores were discussed; and,

f. December 15, 2016, No quality or performance data was presented. No patient satisfaction scores were discussed.

On January 31, 2017, at 8:45 a.m., a meeting involving leadership staff was conducted. When asked what actions were put into place for the identified overcrowding and impediment of flow of patients in the ED, the Interim Director of ED (IDED) stated, facility department managers and the Administrative Clinical Liaison (ACL) were notified to mobilize appropriate resources as needed. The IDED stated, the facility did not have a plan for overcrowding yet. She stated, they were working on a plan to get resources, which she stated, "might include", canceling elective surgeries, putting a hold on accepting transfers from other facilities, and utilizing outpatient, pre and postoperative, and peri-natal space to expand into.

During an interview with the ED Medical Director (EDMD) on January 31, 2017, at 2:10 p.m., the EDMD stated he was aware of the large number of inpatients being held in the ED. The EDMD stated the facility had tried to collect quality indicators, but they kept having leadership turnover, so projects would get started, then they would stop. The EDMD stated with all of the inpatients they were holding in the ED, the overall throughput times would be difficult to improve, as they had, "very few beds," to see ED patients in.

During an interview with the leadership team responsible for ED quality on February 1, 2017, at 9:30 a.m., the Chief of Quality and Patient Safety stated the facility had experienced multiple turnovers in ED leadership that led to data collection starting and stopping. She stated there were plans to begin improving patient flow and processes with the new leadership that was in place.

Based on observation, interview, and record review, the facility failed to provide adequate resources and qualified nursing personnel to meet the needs of the emergency patients when:

1. Inpatient resources (medical surgical, telemetry [heart monitoring], direct observation, and critical care beds) were not made available to Emergency Department (ED) patients when they required admission on 10 of 13 days reviewed (Refer A1103);

2. Additional resources were not made available to the ED when they were holding multiple inpatient admits and when they were, "dangerously overcrowded," according to the NEDOCS score (the facility approved tool used for assessing the level of activity in the ED) (Refer to A1103);

3. Schedules for 5 of 12 days reviewed did not have enough qualified nurses to perform all of the assignments necessary to ensure safe flow of patients from arrival to discharge (Refer to A1112);

4. ED nursing staff was providing care to inpatients on 7 of 12 days reviewed, leaving them with inadequate numbers of nurses to care for the ED patients who were requesting care (Refer to A1112); and,

5. One of one Registered Nurses observed (RN 5) was unable to demonstrate correct use of the pediatric resuscitation system and cart; (Refer to A1112).

The cumulative effect of these systemic problems resulted in failure to ensure care in the Emergency Department was provided in a safe and effective manner.

35056

Based on observation, interview, and record review, the facility failed to ensure:

A. Inpatient resources (medical surgical, telemetry [heart monitoring], direct observation, and critical care beds) were made available to Emergency Department (ED) patients when they required admission on 10 of 13 days reviewed; and,

B. Additional resources were made available to the ED when they were holding multiple inpatient admissions, and when they were, "dangerously overcrowded," according to the NEDOCS score (the facility approved tool used for assessing the level of activity in the ED).

These failed practices may have contributed to the death of one patient (Patient 8), and did result in the continued lack of beds available to treat ED patients, a continued lack of qualified ED nurses available to care for ED patients, delay in care for two patients (Patients 26 and 32), and the had potential to result in harm or death to all patients presenting for care in the ED.

Findings:

NEDOCS scores
[The facility used a nationally recognized tool to assess the level of activity in the Emergency Department (ED). The National Emergency Department Overcrowding Scale (NEDOCS) calculates a score based on specific criteria occurring in the ED at a given time as follows:

* Number of patients in the ED
* Admitted patients in the ED (waiting to transfer to an inpatient area)
* Ventilated patients (patients requiring mechanical breathing machines)
* The longest time a patient with admit orders has been waiting to be transferred to a room
* Longest time of patient in waiting room until time of being seen
* Total number of ED beds
* Total number of hospital beds

Based on these criteria, a score is calculated. The scores range between zero and 200.

0-20 = Not busy
21-60 = Busy
61-100 = Extremely busy but not overcrowded
101-140 = Overcrowded
141-180 = Severely overcrowded
181-200 = Dangerously overcrowded]

ESI levels
[When patients are triaged (initial assessment in the ED), they were assigned an Emergency Severity Index (ESI). According to the facility policy, dated June 17, 2014, titled, "Initial Assessment and Triage - ED" indicated:

ESI 1 "Resuscitation" (patient requires immediate life-saving intervention)

ESI 2 "Emergent" (high risk situation or confused/lethargic/disoriented or severe pain/distress with danger zone vitals for an adult described as a heart rate more than 100, respiratory rate more than 20, and oxygen saturations less than 92%)

ESI 3 "Urgent" (high risk situation, but vitals are not in the danger zone)

ESI 4 "Less Urgent" (only one resource is needed)

ESI 5 "Non-Urgent" (no other resources are needed)]

During an interview with the Interim ED Director (IDED) and the Executive Director of Outpatient Services (EDOPS) on January 31, 2017, at 8:50 a.m., the IDED stated the facility had an ED with 18 beds. The IDED stated in addition to the 18 beds, they had six gurneys in the hallway (for a total of 24 beds), and 12 chairs set aside for Rapid Medical Examination (RME) and patients waiting for discharge (a total of 36 treatment locations).

According to the IDED, the average census in the ED was approximately 3,800 per month (130 patients per day).

The IDED stated the facility was certified as a Chest Pain Center (ability to diagnose and treat patients having a STEMI [heart attack] rapidly, with an electrocardiogram(EKG) immediately on arrival [goal within 10 minutes], appropriate treatment in the ED, and transfer to the cardiac catheterization laboratory [to look for and treat blockages in the coronary arteries] within 30 minutes).

The IDED stated NEDOCS scores of 200 were reported to facility department managers and the Administrative Clinical Liaison (ACL) to mobilize appropriate resources as needed. The IDED stated, the facility did not have a plan for high NEDOCS scores yet. She stated, they were working on a plan to get resources, which she stated, "might include," canceling elective surgeries, putting a hold on accepting transfers from other facilities, and utilizing outpatient, pre and postoperative, and peri-natal space to expand into.

The IDED stated the ED was staffed for all of the beds to be in use 24 hours a day, seven days a week, as follows:

A charge nurse (not counted in the licensed nurse to patient ratios) to make staff assignments, manage the flow of the patients through the department, and provide support to the staff as needed;

A quick view nurse (QVN) located in the lobby 24 hours a day to visualize every patient who presented for care, perform a rapid assessment, assign an Emergency Severity Index level, and monitor patients who were waiting for examination/treatment/discharge) (not counted in the licensed nurse to patient ratios);

An intake (triage) nurse (located inside the ED to perform a more thorough assessment on every patient, and work with the medical staff to expedite the diagnosis and treatment of patients) (not counted in the licensed nurse to patient ratios); and,

One nurse for every four treatment areas (for 36 treatment areas, nine nurses would be required).

A review of the ED Daily Staffing Assignment document indicated the planned staffing included a charge nurse, a QVN, a triage nurse, and four nurses from 7 a.m. to 7 p.m. (enough to care for 16 patients), with a charge nurse, a QVN, a triage nurse, and five nurses from 7 p.m. to 7 a.m. (enough to care for 20 patients). In addition there were 9 a.m. to 9 p.m., 11 a.m. to 11 p.m., 3 p.m. to 3 a.m., and 5 p.m. to 5 a.m., shifts where nurses were scheduled to come and go. The document contained areas for the charge nurses to document the NEDOCS Score at intervals throughout the 24 hour day/night (at 7 a.m., 11 a.m., 3 p.m., 7 p.m., 11 p.m., and 3 a.m.), and for, "Communication For Leadership."

A review of Daily Staffing Assignments completed by the charge nurses indicated the following:

1. On October 13, 2016:

a. At 7 p.m.,

- There were four admitted patients in the ED waiting for inpatient beds and being cared for by ED nurses;

- The department had 55 total patients receiving or waiting to receive care; and

- The NEDOCS score was 200 (dangerously overcrowded), with no evidence of additional resources sent to the ED to assist.

b. At 11 p.m.,

- There was one admitted patient waiting for a medical surgical bed being cared for by an ED nurse and there were two critical care patients waiting for beds in the intensive care unit (ICU) being cared for by ED nursing staff;

- The department had 30 total patients receiving or waiting to receive care; and

- The QVN left, leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients.

2. On October 20, 2016:

a. At 3 p.m.,

- There were three admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- There were two admitted critical care patients waiting for ICU beds and being cared for by the ED nurses; and

- The department had 47 total patients receiving or waiting to receive care.

b. At 7 p.m.:

- There were four admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses; and

- The department had 64 total patients receiving or waiting to receive care.

c. At 11 p.m.:

- There were six admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- The department had 44 total patients receiving or waiting to receive care; and

- The QVN left, leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients.

d. At 3 a.m.:

- There were 13 admitted patients in the ED waiting for inpatient beds, and one patient admitted waiting for a Progressive Care Unit (PCU) bed, and being cared for by the ED nurses; and

- The department had 16 total patients receiving or waiting to receive care.

e. The NEDOCS scores at 7 p.m, 11 p.m., and 3 a.m. were 200 (dangerously overcrowded), with no evidence of additional resources sent to the ED to assist.

3. On October 21, 2016:

a. At 11 a.m.,

- There were 14 admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses; and

- The department had 46 total patients receiving or waiting to receive care.

b. At 3 p.m.,

- There were nine admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses; and

- The department had 51 total patients receiving or waiting to receive care.

c. At 11 p.m.,

- There were six admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- The department had 30 total patients receiving or waiting to receive care; and

- The QVN left, leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients.

d. The NEDOCS scores from 7 a.m. to 11 p.m. were 200 (dangerously overcrowded), with no evidence of additional resources sent to the ED to assist.

Record reviews for patients who presented to the ED on October 21, 2016, revealed Patient 8 presented to the ED waiting room at 4:41 p.m., via wheelchair for complaint of difficulty breathing and abdominal distention. Patient 8 was assessed in Triage at 4:54 p.m. Blood pressure was 89/59 millimeters of mercury (normal value of 120/80), pulse 104 beats per minute (normal range 60 to 100), respiratory rate 36 breaths per minute (normal range 12 to 20), and oxygen saturations 84% (normal range 95 to 100%). Patient 8 was assigned an ESI of 2 (emergent) by Triage Nurse (TN) 1.

Patient 8 record indicated he was assessed by the Physician at 5:10 p.m. The Physician's documentation indicated, he was aware of Patient 8's vital signs, and ESI of 2. The Physician documented Patient 8 was alert and oriented. Physician orders included, "...cardiac [heart] monitoring..., pulse oximetry [measuring oxygen content]..., peripheral IV [intravenous] insertion..." There was no documentation that indicated the orders were initiated prior to placing the patient back into the ED waiting room.

In addition, based on presenting symptoms, Patient 8 triggered a requirement for the facility's Sepsis (a toxic condition rising from an infection) Protocol. The Sepsis Protocol approved July 29, 2016, indicated, a set of orders to be implemented to include intravenous (IV) access be started.

Video footage of the facility's ED waiting room for October 21, 2016, was reviewed. The video footage revealed Patient 8 entered the facility ED at 4:35 p.m., in a wheelchair with an escort. According to the patient's record, TN 1 assessed Patient 8 at 4:41 p.m., and the physician assessed him at 5:10 p.m.

Video footage revealed Patient 8 was seen returning to the waiting room at 6:08 p.m., in a wheelchair, and his escort was assisting by pushing an oxygen tank with tubing connected to the patient. Patient 8 was positioned with his back and part of his right side facing the camera. QVN 2 was at the ED waiting room desk about 10 or 12 feet away. Patient 8's escort sat down next to him on his left side. At 6:48:42 p.m., (40 minutes later) Patient 8's escort stood up and faced the patient. She alerted someone at the reception desk. At 6:49:30 p.m., (41 minutes after returning to the waiting room), the ED Technician (EDT) 1 was observed checking oxygen saturations. At 6:49:42 p.m., EDT 1 appeared to talk to QVN 2 at the reception desk. At 6:50:23 p.m., EDT 1 brought an automated machine to check Patient 8's blood pressure and heart rate, although results were not documented in the medical record. At 6:51:42 p.m., EDT 1 walked to the right, out of camera view. At 6:52:40 p.m., EDT 1 returned with a blanket and placed it around Patient 8. At 6:54:30 p.m., RN 4 checked Patient 8 and at 6:54:38 p.m., (46 minutes after returning to the waiting room, with an ESI of 2 [emergent]), RN 4 wheeled Patient 8 out of camera view, into the ED treatment area. According to the medical record, resuscitative efforts began at 6:55 p.m., and Patient 8 was pronounced dead at 7:21 p.m. on October 21, 2016.

Documentation by Physician 1 indicated, "...Medical Decision Making: This patient was initially evaluated in triage. I did discuss with the triage nurse that the patient would require a bed as soon as possible. I then evaluated this patient in the screening area. The patient did require oxygen....A chest x-ray was obtained that showed an enlarged heart. There is infiltrates in both lower lungs...Multiple requests were made to place this patient in a monitored [heart monitor] bed however none were available...The initial plan was to administer antibiotics for the pneumonia. He was also ordered to have a CT [Computerized Tomography] scan to evaluate the abdominal pain. The patient was placed in the waiting room on oxygen by the RME [Rapid Medical Exam, now known as triage] staff. While there he was monitored by the Quick View nursing staff. The patient became more short of breath and then suddenly lost consciousness. He was quickly moved back to the emergency department where CPR [cardiopulmonary resuscitation] was instigated. We did continue CPR, place an IV line...We were unable to resuscitate this patient..."

On January 31, 2017, at 9:20 a.m., QVN 3 was interviewed. QVN 3 was positioned in the ED waiting room. QVN 3 stated, "ESI 1's should go straight to a bed in the ED and with ESI 2's, the Charge Nurse should be notified to open a bed."

4. On January 20, 2017, documents reviewed indicated:

a. At 11 a.m.,

- There were six admitted patients in the ED waiting for inpatient beds, and being cared for by the ED nurses;

- There were four admitted critical care patients waiting for ICU beds, and being cared for by the ED nurses; and

- The department had 40 total patients receiving or waiting to receive care.

b. At 3 p.m.,

- There were 13 admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- There were three admitted critical care patients waiting for ICU beds and being cared for by the ED nurses; and

- The department had 46 total patients receiving or waiting to receive care.

c. At 7 p.m.,

- There were 14 admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- There were three admitted critical care patients waiting for ICU beds and being cared for by the ED nurses; and

- The department had 30 total patients receiving or waiting to receive care.

d. At 11 p.m.,

- There were four admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- There were two admitted critical care patients waiting for ICU beds, and one admitted patient waiting for a PCU bed, and being cared for by the ED nurses;

- The department had 42 total patients receiving or waiting to receive care; and

- The QVN left, leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients. There were four traveler nurses and one new graduate licensed nurse working during the night shift. One of the licensed nurses did not have a triage certification (required by the facility to be assigned to patient care). There were not enough trained, qualified and/or triage certified licensed nurses to cover the quick view and triage assignments.

e. The NEDOCS scores at 7 p.m. and 11 p.m. were 200 (dangerously overcrowded), with no evidence of additional resources sent to the ED to assist.

5. On January 21, 2017:

a. At 7 a.m.,

- There were seven admitted patients in the ED waiting for inpatient beds and one patient admitted to the Progressive Care Unit (PCU), being cared for by the ED nurses; and

- The department had 30 total patients receiving or waiting to receive care.

b. At 11 a.m.,

- There were six admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses; and

- The department had 46 total patients receiving or waiting to receive care.

c., At 11 p.m.,

- There were ten admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses; and

- The department had 44 total patients receiving or waiting to receive care.

d. At 3 a.m.,

- There were 14 admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- There were two admitted critical care patients waiting for ICU beds, and being cared for by the ED nurses; and

- The department had 30 total patients receiving or waiting to receive care.

e. The NEDOCS scores at 11 a.m., 7 p.m., 11 p.m., and 3 a.m. were 200 (dangerously overcrowded), with no evidence of additional resources sent to the ED to assist.

Record reviews for patients who presented to the ED on January 21, 2017, indicated Patient 26, a 64 year old female, presented to the ED complaining of bilateral flank pain (pain on both sides in the areas of her kidneys) and vomiting at 9:11 a.m. Patient 26 record indicated the patient stated she was a diabetic, she had been seen in an ED four days earlier, diagnosed with a kidney infection, and her condition had worsened since that time.

According to the record, the patient's initial vital signs included a heart rate of 111 (elevated - normal 80-100), with a respiratory rate of 22 (elevated - normal 12-20). There was no assessment of the patient's blood sugar done by the QVC or triage nurse. to assist in determining the urgency of her condition.

Patient 26 was placed in the lobby for 36 minutes (until 9:47 a.m.), when she received a medical screening examination by a physician's assistant, and had labs drawn. She was placed back in the lobby at 10:17 a.m.

Lab results (with a draw time of 10:10 a.m.) indicated Patient 24 had a high white blood cell count (indicating the presence of an infection), a high blood sugar of 433 (normal 70-100), and a low carbon dioxide level with a high anion gap of 26 (normal 11 or less) (indicating an acidotic state - with the body producing excessive quantities of acid).

At 1:53 p.m. (three hours and 36 minutes after being placed back in the lobby), Patient 26 was taken to a bed in the ED for treatment.

The ED Physician's Note indicated Patient 26 was diagnosed with a kidney infection, dehydration, a "significantly" elevated blood sugar, and diabetic ketoacidosis (a life threatening condition that develops when the body's cells are unable to get the sugar they need for energy due to lack of insulin - characterized by symptoms that include high blood sugar, rapid breathing, high heart rate, dehydration, nausea, and vomiting). The note indicated the physician spent 35 minutes of, "critical care time," with Patient 26.

Admission orders were written for inpatient treatment, and Patient 26 remained in the ED being cared for by the ED nursing staff over night. The record indicated the patient was transferred to an inpatient bed on January 22, 2017, at 9:02 a.m. (23 hours and 53 minutes after presenting to the ED for treatment).

6. On January 22, 2017:

a. At 11 p.m.,

- There were ten admitted patients in the ED waiting for inpatient beds and one patient admitted waiting for a PCU, and being cared for by the ED nurses; and

- The department had 38 total patients receiving or waiting to receive care (not including the admitted patients).

b. The NEDOCS scores at 7 p.m. and 11 p.m. were 200 (dangerously overcrowded), with no evidence of additional resources sent to the ED to assist.

7. On January 27, 2017:

a. At 3 p.m.,

- There were 11 admitted patients in the ED waiting for inpatient beds and one patient admitted waiting for a PCU, and being cared for by the ED nurses; and

- The department had 50 total patients receiving or waiting to receive care.

b. At 11 p.m.,

- There were three admitted patients in the ED waiting for inpatient beds, and being cared for by the ED nurses; and

- The department had 36 total patients receiving or waiting to receive care.

c. The NEDOCS scores at 7 a.m., 3 p.m., 7 p.m. and 11 p.m. were 200 (dangerously overcrowded), with no evidence of additional resources sent to the ED to assist.

d. The QVN left left at 3 a.m., leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients.

8. On January 28, 2017:

a. At 3 p.m.,

- There were four admitted patients in the ED waiting for inpatient beds, and being cared for by the ED nurses; and

- The department had 37 total patients receiving or waiting to receive care.

b. At 7 p.m.,

- There were six admitted patients in the ED waiting for inpatient beds, and being cared for by the ED nurses; and

- The department had 39 total patients receiving or waiting to receive care.

c. At 11 p.m.,

- There were three admitted patients in the ED waiting for inpatient beds, and one admitted patient waiting for a PCU bed, and being cared for by the ED nurses;

- The department had 36 total patients receiving or waiting to receive care; and

d. There was no evidence of additional resources sent to the ED to assist.

9. During a tour of the ED on January 31, 2017, between 8 p.m. and 9:30 p.m., accompanied by the ED Charge Nurse (EDCN) 2 the department was observed to have 10 admitted patients being held in the ED, waiting to be transferred to inpatient beds.

a. The patient in Bed 1 had been in the ED for five hours and 10 minutes, and was waiting for a telemetry (cardiac monitoring) bed;

b. The patient in Bed 2 had been in the department for 6 1/2 hours, and was waiting for a telemetry bed;

c. The patient in Bed 3 had been in the department for five hours and 18 minutes, and was waiting for a telemetry bed;

d. The patient in Bed 5 had been in the department for 10 hours, and was waiting for a telemetry bed;

e. The patient in Bed 8 had been in the department for four hours and eight minutes, and was waiting for a telemetry bed. According to the EDCN and the nurse caring for the patient, a room had been assigned, but when she called to give report, the inpatient nurse would not take it at that time;

f. The patient in Bed 9 had been in the department for seven hours and 15 minutes, and was waiting for a telemetry bed;

g. The patient in Bed 10 had been in the department for nine hours and 50 minutes, and was waiting for a medical surgical bed. According to EDCN 2 and the information appearing on the bed board computer, a room had been assigned but was, "dirty," so they could not yet give report and send the patient to the floor;

h. The patient in Bed 18 had been in the department for nine hours and 55 minutes, and was waiting for a direct observation unit bed (closer monitoring with a 1:3 nurse to patient ratio). According to EDCN 2 and the nurse caring for the patient, the bed had been assigned and the nurse called to give report on the patient, but the inpatient nurse would not take report and accept the patient, as the bed had been taken away to be saved for a STEMI (heart attack) patient that was coming from a different facility, so the patient had to stay in the ED;

i. The patient in Bed J had been in the department for seven hours and 21 minutes, and was waiting for a telemetry observation bed. EDCN 2 stated they had to wait for a bed in the observation unit to open, as they were not allowed to send observation patients to inpatient beds, and

j. The patient in Bed N had been in the department for 4 1/2 hours, and was waiting for a medical surgical observation bed. EDCN 2 stated they had to wait for a bed in the observation unit to open.

Further review of the computerized bed board indicated three telemetry beds on the fifth floor were empty and clean. The EDCN 2 stated there were three floors that admitted telemetry patients, the 3rd, 4th, and 5th floors. EDCN 2 stated they had to wait for the Charge Nurses (CNs) on the telemetry floors to determine if they would take the patients before the patients would be assigned a bed.

During the ED observation, a STEMI patient was observed being taken to an ED bed, and ED staff were pulled from their patients to provide immediate care. This patient was accepted and transferred from another facility.

During an interview with the Administrative Clinical Liaison (ACL) on January 31, 2017, at 8:45 p.m., the ACL stated the following:

a. Surgery patients got admitted before ED patients, because the nurses in the surgery department were eight hour employees and needed to go home;

b. The telemetry beds that were empty might have ED patients assigned to them, and that would be decided after the CN on the telemetry unit reviewed the vital signs, labs, and medical problems to determine whether the patient was appropriate to come to that floor, as the CN made the decision regardless of what the physician order was;

c. He was aware the facility accepted a patient from another facility, even though they did not have the staff or the beds to care for the patient (with 10 inpatients holding in the ED); and,

d. He was aware of the 10 patient holds in the ED, but did not have any additional resources to send to the ED to assist.

On January 31, 2017, at 5:41 p.m., Patient 32, a 59 year old male, arrived by ambulance with complaints of chest pain. The record indicated the EDCN on duty at the time (EDCN 1) completed an initial assessment on the patient, as there was no ED bed available, and no available staff. No EKG was performed on the patient (although the patient's complaints met criteria that would trigger the facility's chest pain protocol which included an EKG on arrival). The patient was assigned an ESI of 3 (although facility's policy and procedure indicated the patient met criteria for ESI 2).

According to the record, an EKG was performed at 6:37 p.m. (56 minutes after arriving with chest pain). The EKG results indicated Patient 32 was having a heart attack, the cardiologist (heart specialist) was called, and the patient was treated in the ED then taken to the cardiac catheterization laboratory (to look for blockages in the coronary arteries).

The patient's medical record indicated on February 1, 2017, Patient 32 was still in the hospital being treated for heart failure.

On January 31, 2017, at 8:08 p.m., the ED waiting room was observed along with QVN 4. QVN 4 greeted arrivals at the front desk. Patients or escorts with patients were asked to sign in, fill out a short questionnaire and were asked what their chief complaint was. Visitors also arrived through this area and the QVN asked them to sign in, asked where they were going, gave them a visitor sticker, and gave them directions as needed. QVN 4 occasionally left the desk area. QVN 4 was also observed answering the phone and working on the computer at the desk.

During a confidential staff nurse interview on January 31, 2017, at 9:55 a.m., the nurse stated if patients were identified as an ESI level 2 or, "just really sick," it was, "not our goal," to put them back out in the lobby, but there were times that it happened. The nurse stated when they were assigned to quick view, they sat by the triage door so they could be, "closer to the 2's."

On January 31, 2017, at 10:08 a.m., Registered Nurse (RN) 5 was interviewed. RN 5 stated, "Patients with an ESI of 3, 4, or 5 may go to a chair. ESI 2 patients generally do not go out to the waiting room. If there is a 2 in the waiting room, they are monitored by the Quick View Nurse."

During a confidential staff nurse interview on January 31, 2017, at 11:20 a.m., the nurse stated there was a, "huge," flow problem in the facility. The nurse stated they could not get patients admitted to the inpatient areas, causing a backup of patients in the ED. The nurse stated when there was an inpatient bed assigned for an ED patient, often the nurse on the inpatient floor would not take report and accept the patient, causing further delays and backup of patients. The nurse stated there were times they were, "forced," to put 2s (ESI level 2 patients) in the lobby because of the lack of available beds for them in the department. The nurse stated it was, "just a matter of time before something bad happened."

On January 31, 2017, at 4 p.m., RN 6 was interviewed. RN 6 stated, "ESI of 2 should wait in the RTD [Rapid Treatment Disposition) area, not in the waiting room."

35056

Based on observation, interview, and record review, the facility failed to provide adequate numbers of qualified nursing personnel to meet the needs of the emergency patients when:

1. Schedules for 5 of 12 days reviewed did not have enough qualified nurses to perform all of the assignments necessary to ensure safe flow of patients from arrival to discharge;

2. ED nursing staff was providing care to inpatients on 7 of 12 days reviewed, leaving them with inadequate numbers of nurses to care for the ED patients; and,

3. One of one Registered Nurses observed (RN 5) was unable to demonstrate correct use of the pediatric resuscitation system and cart;

These failed practices may have contributed to the death of one patient, caused a delay in diagnosis of a heart attack for one patient, and had the potential for delays in care, harm, or death for all patients presenting to the ED.

Findings:

1. A review of Daily Staffing Assignments completed by the charge nurses indicated the following:

A. On October 13, 2016, at 11 p.m., the quick view nurse (QVN) left, leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients.

B. On October 20, 2016, at 11 p.m., the QVN left, leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients.

C. On October 21, 2016, at 11 p.m., the QVN left, leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients.

D. On January 20, 2017, at 7 p.m.:

- There were three admitted patients with orders to go to the critical care unit, and an additional 14 admitted patients with orders to go to the medical surgical and telemetry units; and

- The staffing included a charge nurse, two experienced ED nurses (with one leaving at 11 p.m.), one new graduate nurse, two newly hired nurses (at the facility for one month), and five travelers (with one leaving at 11 p.m.).

During an interview with the ED Charge Nurse (EDCN 2) on January 31, 2017, at 8 p.m., the EDCN stated she notified the Administrative Clinical Liaison (ACL) that night that the staffing in the ED was not safe considering the number and acuity of the patients and the experience and capability of the staff. The EDCN stated she requested that the ACL notify her manager, but he, "did not." According to the EDCN, the ACL did not report to the ED to assist, or send resources to the ED to provide assistance.

E. On January 20, 2017, at 11 p.m., the QVN left, leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients. There were four traveler and one new graduate licensed nurses working during the night shift. One of the licensed nurses did not have a triage certification. There were not enough trained, qualified and/or triage certified licensed nurses to cover the quick view and triage assignments.

F. On January 27, 2017, at 11 p.m., the QVN left at 3 a.m., leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients.

2. A review of Daily Staffing Assignments completed by the charge nurses indicated the following (the number of licensed nurses who could take care of patients in the ED would not include the charge nurse, QVN, and the triage nurse as they could not leave their assigned posts to care for other patients):

A. On October 13, 2016:

a. At 7 p.m.,

- There were four admitted patients in the ED waiting for inpatient beds who were being cared for by ED nurses (which would have needed at least need one licensed nurse);

- The department had 55 total patients receiving or waiting to receive care; and

- There were a total of 11 licensed nurses to care for the admitted patients and the rest of the patients in the ED.

b. At 11 p.m.,

- There was one admitted patient waiting for a medical surgical bed being cared for by an ED nurse and there were two critical care patients waiting for beds in the intensive care unit (ICU)(who needed at least one nurse); being cared for by ED nursing staff;

- The department had 30 total patients receiving or waiting to receive care;

- There were eight licensed nurses to care for the admitted patients and the rest of the patients in the ED.

- The QVN left, leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients.

B. On October 20, 2016:

a. At 3 p.m.,

- There were three admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- There were two admitted critical care patients waiting for ICU beds and being cared for by the ED nurses (these patients would have taken a licensed nurse away from care of other ED patients);

- The department had 47 total patients receiving or waiting to receive care; and

- There were 11 licensed nurses to take care of the admitted patients and the rest of the patients in the the ED.

b. At 7 p.m.:

- There were four admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- The department had 64 total patients receiving or waiting to receive care;

- There were 11 licensed nurses to take care of the admitted patients and the rest of the patients in the the ED.

c. At 11 p.m.:

- There were six admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- The department had 44 total patients receiving or waiting to receive care;

- There were eight licensed nurses to take care of the admitted patients and the rest of the patients in the the ED; and

- The QVN left, leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients.

C. On October 21, 2016:

a. At 11 a.m.,

- There were 14 admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses; and

- The department had 46 total patients receiving or waiting to receive care; and

- There were ten licensed nurses to take care of the admitted patients and the rest of the patients in the the ED.

b. At 3 p.m.,

- There were nine admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses; and

- The department had 51 total patients receiving or waiting to receive care;

- There were 11 licensed nurses to take care of the admitted patients and the rest of the patients in the the ED.

c. At 11 p.m.,

- There were six admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- The department had 30 total patients receiving or waiting to receive care;

- There were six licensed nurses to take care of the admitted patients and the rest of the patients in the the ED; and

- The QVN left, leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients.

D. On January 20, 2017:

a. At 11 a.m.,

- There were six admitted patients in the ED waiting for inpatient beds, and being cared for by the ED nurses;

- There were four admitted critical care patients waiting for ICU beds, and being cared for by the ED nurses (these patients needed at least two licensed nurses to care for them);

- The department had 40 total patients receiving or waiting to receive care; and

- There were ten licensed nurses to take care of the admitted patients and the rest of the patients in the the ED.

b. At 3 p.m.,

- There were 13 admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- There were three admitted critical care patients waiting for ICU beds and being cared for by the ED nurses (these patients needed one to two licensed nurses to care for them);

- The department had 46 total patients receiving or waiting to receive care; and

- There were ten licensed nurses to take care of the admitted patients and the rest of the patients in the the ED.

c. At 11 p.m.,

- There were four admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- There were two admitted critical care patients waiting for ICU beds (these patients needed one licensed nurses to care for them), and one admitted patient waiting for a Progressive Care Unit (PCU) bed, and being cared for by the ED nurses;

- The department had 42 total patients receiving or waiting to receive care;

- There were eight licensed nurses to take care of the admitted patients and the rest of the patients in the the ED; and

- The QVN left, leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients. There were four traveler and one new graduate licensed nurses working during the night shift. One of the licensed nurses did not have a triage certification. There were not enough trained, qualified and/or triage certified licensed nurses to cover the quick view and triage assignments.

E. On January 21, 2017:

a. At 7 a.m.,

- There were seven admitted patients in the ED waiting for inpatient beds and one patient admitted to the PCU, and being cared for by the ED nurses; and

- The department had 30 total patients receiving or waiting to receive care; and

- There were five licensed nurses to take care of the admitted patients and the rest of the patients in the the ED.

b. At 11 a.m.,

- There were six admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- The department had 46 total patients receiving or waiting to receive care; and

- There were eight licensed nurses to take care of the admitted patients and the rest of the patients in the the ED.

c. At 11 p.m.,

- There were ten admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- The department had 44 total patients receiving or waiting to receive care; and

- There were eight licensed nurses to take care of the admitted patients and the rest of the patients in the the ED.

d. At 3 a.m.,

- There were 14 admitted patients in the ED waiting for inpatient beds and being cared for by the ED nurses;

- There were two admitted critical care patients waiting for ICU beds (these patients needed one licensed nurses to care for them), and being cared for by the ED nurses;

- The department had 30 total patients receiving or waiting to receive care;

- There were six licensed nurses to take care of the admitted patients and the rest of the patients in the the ED.

F. On January 27, 2017:

a. At 11 p.m.,

- There were three admitted patients in the ED waiting for inpatient beds, and being cared for by the ED nurses;

- The department had 36 total patients receiving or waiting to receive care; and

- There were six licensed nurses to take care of the admitted patients and the rest of the patients in the the ED.

b. The QVN left at 3 a.m., leaving the charge nurse responsible for covering the quick view assignment, while still being responsible for managing the flow of patients through the department, and supporting the staff caring for the inpatients.

G. On January 28, 2017, at 3 p.m.:

- There were four admitted patients in the ED waiting for inpatient beds, and being cared for by the ED nurses;

- The department had 37 total patients receiving or waiting to receive care; and

- There were eight licensed nurses to take care of the admitted patients and the rest of the patients in the the ED.

3. On January 31, 2017, at 10:40 a.m., during a tour of the ED, accompanied by the Emergency Department Manager (EDM) and Registered Nurse (RN) 5, the EDM was interviewed. The EDM stated the facility was using the Broselow system (a universally accepted color-coded system used to resuscitate pediatric patients. The system included:

- The Broselow tape, a color-coded tape to measure the patient's height which corresponded to a color, weight, doses of medications, and appropriate equipment to maintain the airway;

- The Broselow cart with color-coded drawer (matching the Broselow tape) containing the corresponding appropriate equipment and emergency medication; and

- A manual that listed the doses of medications and equipment corresponding to the color).

When RN 5 was demonstrating how to use the Broselow tape, RN 5 was observed to begin measurement at the end of the red colored area instead of the end of the tape marked by an arrow and labeled "measure from this end."

RN 5 was asked about the appropriate dose for Atropine (medication to treat slow heartbeat). RN 5 referred to the list on one side of the tape. RN 5 stated Atropine was not on the list. RN 5 did not look at the other side of the tape where Atropine was listed. After the location was pointed out to RN 5, RN 5 was unable to state the difference between the dose to be given through the veins and the dose to be administered through the endotracheal tube (ETT, tube that passed through the throat to the lungs).

RN 5 referred to the Broselow tape when she was asked for the dose of Atropine. RN 5 did not refer to the manual which was located on top of the cart.

The EDM was asked what reference the facility was using for the doses of the medications during a resuscitation, the EDM stated the facility referred to the manual.

The Broselow tape for the red color indicated the dose of Atropine 0.4 milligrams per milliliter (mg/ml) for ETT was 0.45 mg (equivalent to 1.1 ml). The manual indicated the dose of Atropine ETT for the red color was 0.65 ml (equivalent to 0.26 mg). If the nurse used the Broselow tape to refer to for the dose of Atropine to be administered through the ETT, the nurse would have administered twice as much Atropine as what was indicated on the manual. The two references did not match. RN 5 did not know which reference to use.

The Broselow cart was inspected with the EDM and RN 5. RN 5 was not able to locate the ETT blade (a piece of plastic or metal used to visualize the airway during the insertion of the ETT).

After observing the demonstration by RN 5, the EDM stated she used to review use of the Broselow cart/system at the annual skills updates for all ED staff, but it was changed last year, and did not include information on the Broselow cart/system.