HospitalInspections.org

Based on observation and staff interview, it was determined that the facility failed to conspicuously post signage, specifying the rights of individuals under section 1866 of the Act with respect to examination and treatment of emergency medical conditions and women in labor.

Findings include:

1. A tour of the Capital Health at Deborah- Emergency Services, conducted on 8/13/19, revealed that there were no EMTALA signs posted in following area:

a. Observation Room #5

2. A tour of the Capital Health at Deborah- Emergency Services, conducted on 8/13/19, revealed that the EMTALA signage posted in the following area was not visible to all patients and visitors:

a. ED waiting area

3. The above findings were confirmed with Staff #1, Staff #2, and Staff #3.



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4. A tour of the Capital Health Medical Center- Hopewell Campus, conducted on 8/13/19, revealed that there were no EMTALA signs posted in the following areas:

a. ED Family Consultation Room

b. ED Hallway areas where patients can be placed (Hallway A#8, #14 and #13)

c. Observation Unit - Rooms #2101-2116

d. The above findings were confirmed by Staff #3 at 11:30 AM.

5. A tour of the Capital Health Medical Center- Hopewell Campus, conducted on 8/13/19, revealed that the EMTALA signage posted in the following area was not visible to all patients and visitors:

a. In the ED large waiting area

b. The above finding was confirmed by Staff #1 at 10:20 AM.

DEBORAH CAMPUS

Based on medical record review, review of facility documents, and staff interviews, it was determined that the facility failed to ensure all individuals presenting to the Emergency Department (ED) are triaged at the time of arrival and/or are given a timely medical screening exam (MSE).

Findings include:

Reference #1: Facility policy "Documentation in the Emergency Department: Guidelines" states, " ...PROCEDURE: ...A. ...2. initial assessment (triage) is expected to determine the patient's immediate needs, whether they are acute or chronic, require immediate or delayed intervention, and to assign the patient a priority for this intervention. ..."

Reference #2: Facility policy "Emergency Care" states, " ...Medical Screening Examination ...5. Patients leaving prior to Medical Screening Examination- When a Patient expresses an intent to leave prior to being treated, staff offers a Medical Screening Examination during triage, and informs the Patient of the risks and benefits of the examination, treatment or both, if applicable. a. If the Patient refuses the Medical Screening Examination, document the refusal and the risks/benefits of the examination explained to the Patient, and the reasons for refusal and the steps taken to try to secure the written informed refusal if it was not obtained, using the "Refusal of Examination or Treatment" form ..."

Reference #3: Facility policy "Triage" states, " ...For patient's that leave without being seen, the nurse will make 3 attempts to locate the patient and document the time those attempts were made. ..."

1. Review of Medical Record #1, revealed the following:

a. The Patient arrived to the ED on 7/12/19 at 7:33 PM, with complaints of sharp stabbing pain on the left side.

b. The Patient was triaged at 8:11 PM, and assigned an Emergency Severity Index (ESI) level three (3).

c. The "Clinical Note" on 7/13/19 at 1:42 AM, states " LWOBS [left without being seen]-Pt [patient] informed staff that [he/she] no longer wishes to wait to be seen by MD. Informed staff that [he/she] is leaving. ..."

i. There was no evidence that the Patient, after waiting six (6) hours and nine (9) minutes, in the ED, received an MSE.

ii. When the Patient expressed an intent to leave prior to being treated, there was no evidence that the facility adhered to their policy of reviewing the risks and benefits of leaving with the Patient, and/or to try and secure a written informed refusal.

2. The above findings were confirmed with Staff #2, Staff #3, and Staff #5.

3. Review of Medical Record #2, revealed the following:

a. The Patient arrived to the ED on 7/12/19 at 10:37 PM, with complaints of sore throat, fever and pain.

b. The Patient was triaged at 10:58 PM, and assigned and ESI level four (4).

c. The "Clinical Note" at 2:36 AM, states " ...LWOBS- Patient called for the 3rd time. No answer. ..."

i. There was no evidence that the Patient, after waiting three (3) hours and fifty-nine (59) minutes in the ED, received an MSE.

ii. There was no documented evidence that the nurse made three attempts to locate the patient.

4. Review of Medical Record #3, revealed the following:

a. The Patient arrived to the ED on 7/12/19 at 5:28 PM, with complaints of "pain, 29 weeks pregnant, lower back-pelvic and abdominal pain."

b. The Patient was triaged at 7:11 PM, and assigned an ESI level four (4).

c. The "Clinical Note" at 7:51 PM states, " ...LWOBS- Patient not found in the waiting room ... pt [patient] notified ED staff that she was not waiting any more and left ED."

i. There was a delay in triage of one (1) hour and forty-three (43) minutes, from the time of arrival to the ED.

ii. When the Patient expressed an intent to leave the ED,prior to being treated, there was no evidence that the facility adhered to their policy of reviewing the risks and benefits with the Patient and/or trying to secure a written informed refusal.

5. Review of Medical Record #10, revealed the following:

a. The Patient arrived to the ED on 7/12/19 at 4:10 PM, with complaints of "rash, allergic reaction in diaper area."

b. The Patient was triaged at 5:08 PM, and assigned an ESI level of four (4).

i. There was a delay in triage of fifty-eight (58) minutes, from the time of arrival to the ED.

6. Review of Medical Record #11, revealed the following:

a. The Patient arrived to the ED on 7/12/19 at 5:16 PM, with complaints of "cardiac complaint, throat, jaw and chest pain."

b. The "Clinical Note" at 7:41 PM states, " ...NO ANSWER- Patient called for the second time ..." The "Clinical Note" at 8:43 PM states, " ...NO ANSWER- Patient called for the third time ...LWOBS- Patient called for 3rd time. No answer. ..."

i. There was no evidence that the nurse made three attempts to locate the Patient, or document those three attempts.

7. Review of Medical Record #13, revealed the following:

a. The Patient arrived to the ED on 7/12/19 at 4:46 PM, with complaints of "abdominal and back pain, with blood in the urine."

b. The "Clinical Note" at 6:51 PM states, "NO ANSWER- Patient called for the first time ..." The "Clinical Note" at 7:58 PM, states, "NO ANSWER- Patient called for the second time. ...LWOBS ..."

i. The Patient LWOBS two (2) hours and five (5) minutes, from time of arrival, and there was no evidence that the Patient was triaged.

ii. There was no evidence that the nurse made three attempts to locate the Patient, or document those three attempts.

8. The above findings were confirmed with Staff #5 and Staff #6.

DEBORAH CAMPUS

A. Based on medical record review, review of facility documents, and staff interviews, it was determined that the facility failed to ensure that all patients receive full assessments and reassessments, per facility policy.

Findings include:

Reference #1: Facility policy "Documentation in the Emergency Department: Guidelines" states, " ... V. PROCEDURE: A. 1. All patients who present to the ED will have an initial assessment ... 2. This initial assessment (triage) is expected to determine the patient's immediate needs. ... 3. The nursing documentation will include an initial set of vital signs ...C. Reassessments (including a complete set of vital signs) shall be performed as often as required by the patient's condition, but at least every two hours with findings documented. ..."

Reference #2: Facility policy "Triage Policy" states, " ...V. PROCEDURE: 5. ...b. 1. Level 3 patients remaining in the waiting room are reassessed every 90-105 minutes ...c. ...1. Level 4 patients remaining in the waiting room is reassessed every 120-135 minutes ...d. 1. Level 5 patient's remaining in the waiting room are reassessed every 180-195 minutes ... Findings are documented on the patient's chart. ...6. Reassessment and Documention includes: a. Vital signs, pain rating b. General appearance, mental status c. Information relevant to the chief complaint. ..."

Reference #3: Facility policy "Management of Pain Across the Life Span" states, " IV. POLICY. ...B. ...Pain is reassessed within 60 minutes for all routes of administration. ...V. PROCEDURE: ...B. Assessment and Reassessment of Pain ...5. It is the responsibility of the nurse to notify the appropriate LIP [licensed provider] or designee if the patient does not achieve acceptable pain relief. 6. It is the responsibility of the LIP or designee to confer with the patient regarding the level of comfort he or she is experiencing and the desire or need for further intervention. ..."

1. Review of Medical Record #1, revealed the following:

a. The Patient arrived to the ED on 7/12/19 at 7:33 PM, with complaints of sharp stabbing pain on the left side. Pain was assessed at 8:11 PM, and identified as seven (7) out of ten (10) on a numeric pain scale.

b. The Patient was assigned an Emergency Severity Index (ESI) level three (3).

c. In the "Clinical Note" at 11:46 PM, pain was reassessed at 7/10, with the treatment option of heat. The "Clinical Note" at 1:42 AM,, states, " ... LWOBS - Pt [patient] informed staff that she no longer wishes to be seen by MD. Informed staff that [he/she] is leaving. ..."

i. There was no evidence of pain reassessment after the intervention of heat at 11:46 PM.

ii. There was no evidence of vital signs being reassessed after the initial vital signs at 8:11 PM

2. The above finding was reviewed with Staff #2, Staff #3, and Staff #5.

3. Review of Medical Record #2, revealed the following:

a. The Patient arrived to the ED on 7/12/19 at 10:37 PM, with complaints of sore throat, fever and pain. Pain was assessed at 10:59 PM, and identified as six (6) out of ten (10), on a numeric pain scale.

b. The Patient was assigned an ESI level four (4), and initial vital signs were taken at 10:59 PM with a Temperature (F) oral of 100.0.

c. The "Clinical Note" at 2:36 AM, states " ...LWOBS- Patient called for the 3rd time. No answer. ..."

i. There was no evidence that the Patient was reassessed between 12:59 PM and 1:14 AM, while remaining in the waiting room.

4. The above findings were confirmed with Staff #5, and Staff #6.

5. Review of Medical Record #3, revealed the following:

a. The Patient arrived to the ED on 7/12/19 at 5:28 PM, with complaints of "pain, 29 weeks pregnant, lower back-pelvic and abdominal pain." Pain was assessed at 7:13 PM, and identified as a seven (7) out of ten (10).

b. The Patient was assigned an ESI level four (4), and initial vital signs were taken at 7:13 PM.

c. The "Clinical Note" at 7:51 PM states, " ... LWOBS- Patient not found in the waiting room ... pt [patient] notified ED staff that she was not waiting any more and left ED."

i. There was no evidence of nursing intervention for pain.

6. The above findings were confirmed with Staff #5, and Staff #6.

7. Review of Medical Record #6, revealed the following:

a. The Patient arrived to the ED on 7/4/19 at 2:05 AM, with complaints of chest pain. Pain was assessed at 2:07 AM, and identified as nine (9) out of ten (10).

b. The "Primary Nursing Assessment" at 2:08 AM states, " ... Acute pain at 9/10 Numeric, dull in the RUQ [right upper quadrant], ... Other treatment options: distraction. ..."

i. There was no evidence that the Patient's pain was reassessed, 60 minutes post intervention.

8. The above finding was confirmed with Staff #1.

9. Review of Medical Record #7, revealed the following:

a. The Patient arrived to the ED on 7/4/19 at 9:13 AM, with complaints of "pain and swollen leg." Pain was assessed as follows:

9:20 AM: 8/10 on a numeric pain scale
11:54 AM: 7/10 on a numeric pain scale
1:47 PM: 3/10 on a numeric pain scale

b. The "Clinical Notes" at 9:18 AM states, " ... obvious moderate discomfort from pain ..." The "Clinical Notes" at 11:55 AM states, " ... patient reports slight improvement in pain, however now describes pain as throbbing ..." The "Clinical Notes" at 2:01 PM states, " ... acute pain at 3/10 numeric, throbbing ..."

i. There was no documented evidence of any nursing or LIP intervention and/or discussion of pain management, during the course of the ED visit.

10. The above finding was confirmed with Staff #5.

11. Review of Medical Record #11, revealed the following:

a. The Patient arrived to the ED on 7/12/19 at 5:16 PM, with complaints of "cardiac complaint, throat, jaw and chest pain." Pain was assessed at 5:21 PM, and identified as five (5) out of ten (10).

b. The "Primary Nursing Assessment" triage nursing note at 5:24 PM states, " ...Chest Pain (non cardiac) -Onset of mid-sternal chest pain 2 hrs ago while sitting. Pain described as tight, 5/10, radiating to left jaw, nothing worsens Sx. [symptoms] nothing improves Sx. (+) [positive] SOB [shortness of breath], (+) diaphoresis ..."

c. The Patient was assigned an ESI level three (3). Vital signs were taken at 5:21 PM as follows: Blood Pressure- [no value], Pulse- 89, Respirations- 18, Oxygen Saturation- 98.0%, Temperature (F) oral- 97.8.

d. The "Clinical Note" at 7:41 PM states, " ...NO ANSWER- " The "Clinical Note" at 8:43 PM states, " ...NO ANSWER- ...LWOBS- Patient called for 3rd time. No answer. ..."

i. There was no evidence that a blood pressure was taken with the initial vital signs at 5:21 PM.

ii. There was no evidence that the Patient was reassessed, between 6:54 PM and 7:09 PM, while remaining in the waiting room.

12. The above findings were confirmed with Staff #5, and Staff #6.

13. Review of Medical Record #19, revealed the following:

a. The Patient arrived to the ED on 7/4/19 at 6:18 PM, with complaints of "diabetic complication and change in mental status."

b. The Patient was assigned an ESI level two (2). Vital signs at 6:19 PM were as follows: Blood Pressure- 109/56, Pulse- 68, Respirations- 12, Oxygen Saturation- 95.0%, Temperature (F) oral- 99.3.

i. There was no evidence that the Patient's temperature was reassessed and that vital signs were taken every two hours, or one hour prior to discharge.

14. The above findings were confirmed with Staff #6.


DEBORAH CAMPUS

B. Based on medical record review, review of facility documents, and staff interviews, it was determined that the facility failed to ensure their "Adult Initiation of Care" protocols were adhered to.

Findings include:

Reference #1: Facility policy "Guidelines for he Use of "Adult Initiation of Care" for Licensed Nursing Staff in the Emergency Department states, " ...Signs and Symptoms for each category may include (but no necessarily limited to) the following: Category- I. Chest Pain- Signs and Symptoms- Typical: chest pain with or without radiation to arm, neck back or epigastric area. May experience shortness of breath, nausea and lightheadedness ...

Reference #2: Facility document "Emergency Department-Downtime Adult Initiation of Care Protocol Category I-IV ...I. Chest Pain- EKG Routine ...Cardiac Monitor-CBC with Differential- BMP- POC Troponin STAT ...Medication- Oxygen 2L/min [2 liters per minute] O2 [oxygen] by inhalation continuous as needed ...Aspirin chewable tablet (4 tablets of 81 mg/tablet) by mouth once- Saline lock ..."

1. Review of Medical Record #11, revealed the following:

a. The Patient arrived to the ED on 7/12/19 at 5:16 PM, with complaints of "cardiac complaint, throat, jaw and chest pain." Pain was assessed at 5:21 PM, and identified as five (5) out of ten (10).

b. The "Primary Nursing Assessment" triage nursing note at 5:24 PM states, " ...Chest Pain (non cardiac) -Onset of mid-sternal chest pain 2 hrs ago while sitting. Pain described as tight, 5/10, radiating to left jaw, nothing worsens Sx. [symptoms] nothing improves Sx. (+) [positive] SOB [shortness of breath], (+) diaphoresis ..."

c. The "Clinical Note" at 7:41 PM states, " ...NO ANSWER- Patient called for the second time ..." The "Clinical Note" at 8:43 PM states, " ...NO ANSWER- Patient called for the third time ...LWOBS- Patient called for 3rd time. No answer. ..."

2. Upon interview with Staff #6 on 8/14/19 at 9:30 AM, it was confirmed that with the presenting signs and symptoms of Patient #11 on 7/12/19, the ED Chest Pain Protocol should have been initiated and followed.



DEBORAH CAMPUS

C. Based on medical record review, review of facility documents, and staff interview, it was determined that the facility failed to adhere to their elopement policy.

Findings include:

Reference: Facility policy "Elopement/Adult Security System" states, " ...Policy ...When a patient who elopes has been deemed to be a danger to him/herself or others, the Psychiatric Screening Center (PSC) is notified and the Mobile Outreach Team is activated. The local police and the police department where the patient resides are notified. A Safety Report is completed for all patients who have eloped. ...PROCEDURE: ...B. ...Emergency Departments ...2, Contact the Switchboard operator notifies the Security Department via radio. ...3. Attempt to contact the patient. Call the patient's cell phone or home number. 4. ...obtain permission to contact the patient's family or significant other. ..."

1. Review of Medical Record #15, revealed the following:

a. The patient arrived to the ED on 7/12/19 at 1:04 PM, for "psychiatric evaluation with suicidal ideation."

b. The "MD Note" at 3:02 PM states, " ...Pt [patient] jumped out of stretcher and ran out the back entrance. Security was in pursuit of pt. Pt left ER [emergency room], policy was notified by RN. ..."

c. The "Clinical Note" at 3:38 PM states, " ...Sister to ER, states that police have found patient and that [he/she] has been taken over to [name of facility with Screening and Crisis Intervention Program (SCIP)] and police have sent her to collect [his/her] belongings."

2. Upon interview on 8/14/19 at 11:05 AM, Staff #2, and Staff #5 confirmed that the Psychiatric Screening Center (PSC) was not notified, and the switchboard operator was not contacted. It was also confirmed that there was no evidence of an attempt to contact the patient, or obtain permission to contact the patient's family or significant other, per policy.

DEBORAH CAMPUS

D. Based on medical record review, review of facility documents, and staff interview, it was determined that the facility failed to adhere to their observation policy.

Findings include:

Reference: Facility policy "Levels of Observation & Video Monitoring" states, " ...Procedure: A. Level of Observation- ...2. The LIP [licensed independent practitioner] is notified when a patient is placed on a level of observation. 3. An LIP order is obtained ONLY for patients who require a level of observation for psychiatric issues. ..."

1. Review of Medical Record #15, revealed the following:

a. The patient arrived to the ED on 7/12/19 at 1:04 PM, for a "psychiatric evaluation with suicidal ideation and wants to end it all."

b. The "Primary Nursing Assessment" at 1:32 PM states, " ...Pt [patient] brought by police for psychiatric evaluation. ...Patient was placed on Level of Obs [observation]. ..."

2. Upon interview on 8/14/19 at 11:05 AM, Staff #2 and Staff #5 confirmed that there were written observation orders for Level of Obs [observation].

DEBORAH CAMPUS

Based on medical record review, review of facility documents, and staff interview, it was determined that the facility failed to ensure their transfer policy was adhered to.

Findings include:

Reference: Facility policy "Emergency Care" states, " ...h. ...compliance with this policy ...at a minimum will include the following elements: ...vill. Receiving physician ..."

1. Review of Medical Record #20, revealed the following:

a. The Patient arrived to the ED on 8/4/19 at 6:12 PM. At 8:19 PM, the physician ordered the Patient to be transferred to a higher level of care.

b. The Patient was transferred out at 11:25 PM by advanced life support.

i. Page two of three of the "Emergency Department Patient Transfer" form, under "My physician recommends that I be transferred to the service of Dr. ______," was not completed.

2. The above finding was confirmed with Staff #6.