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Based on interviews with staff, document reviews and observations during a survey on January 11-12, 2018, it was determined the hospital was out of compliance with the Condition of Governing Body.

Specifically, the Emergency Department (ED) identified a problem with patient access in August 2017, yet no evidence was found during the survey that leadership was aware of the situation or involved in remediation. In meeting minutes from the ED quality council in August, 2017 nd reviewed by the surveyors on January 11, 2018, ED staff identified that the process of security personnel turning away patients presenting for treatment prior to any clinical assessment was problematic. An education plan was derived. However, no further documentation could be found indicating what, if anything, staff or hospital leadership did to remediate this practice. In addition, current QAPI data reviewed during the survey on 1/11/18 indicated no additional follow-up or data collection. In addition, leadership also failed to identify inaccuracies in the ED Log, possibly unsafe discharge practices and possible patient harassment by security staff.

See A0283

Based on interviews with staff, document reviews and observations, during the survey on January 11-12, 2018, it was determined the hospital is out of compliance with the Condition of Patient Rights. Specifically, the hospital enacted barriers to patients receiving care in the Emergency Department, failed to discharge a patient in a safe manner from the Emergency Department, and failed to protect one patient from harassment and potential harm as cited in more detail under A0144, A0145, and A0146.

Based on observations and interviews in the emergency department (ED and review of documentation on January 11, 2018, it was determined that the hospital failed to provide care in a safe setting for emergency department patients as evidenced by the physical layout of the ED access point which prevented patient access to the ED, and by the fact that not all ED staff have badge access through locked entrance and exit doors.

Surveyors observed that the entrance door for walk-in patients to the ED was locked with access controlled by hospital security personnel. During an interview on 1/11/8, security personnel indicated that they would turn patients away if they were "unruly" or otherwise acting inappropriately. This practice meant that non-clinical personnel determined who could receive treatment in the ED.

In addition, in a review of documentation on 1/11/18 regarding patient #1, who was seen in the ED on 1/9/18, it was determined that the case manager who saw patient #1 in the ED was unable to assess patient needs because the case manager's badge would not open the exit door.

Pt# 1 departed the ED prior to the case manager's assessment and the case manager attempted to exit the ED as Pt# 1 left the ED vicinity. The hospital did not provide a functioning ID badge to case management personnel and the case manager was denied access through a secured exit door, preventing the case manager from completing the evaluation of pt. #1.

Based on review of medical records, interviews with staff, and security camera footage on 1/11/2018, it was determined the hospital neglected to keep Patient #1 safe from harm as evidenced by the failure of Emergency Department (ED) staff to properly execute Pt# 1's discharge plan.

Documentation indicated that Pt# 1 was admitted to the ED via ambulance with a head injury from a fall off of a motorized bicycle on an early January 2018 evening. Pt# 1 was triaged, examined and medically cleared for discharge by medical staff at 2300. Pt# 1 was resistant to discharge and refused to get dressed into street clothes when requested by nursing. Pt# 1's discharge plan was documented as transport via taxi cab to a cold-weather shelter where a female bed had been arranged by case management. Medical record documentation indicated that Pt#1 agreed to the discharge plan but the patient became resistant to going and stopped responding to staff. Nursing requested assistance from the security staff . At approximately 2330, Pt# 1 was given her belongings escorted out of the ED by security staff while wearing only a hospital gown and socks to a nearby bus stop and was left there in approximately 30 degree Fahrenheit weather. The documentation failed to indicate whether it was nursing or security who made the decision to remove Pt #1 from the ED.

Based on documents reviewed at the time of the survey, it was determined the hospital failed to ensure the confidentiality of patient records in 1 of 25 records reviewed. Review of Pt# 1's medical record and related documents revealed statements by non-clinical staff that non-clinical staff had access to or were made aware of portions of Pt #1's medical history and physical examination findings. Pt# 1 presented to the Emergency Department where diagnostic processes were performed. Non-clinical staff assisted clinical staff in the discharge of Pt# 1. A subsequent written statement by non-clinical staff that pertained to Pt# 1's discharge included confidential diagnostic and medical history information not required in the execution of their prescribed duties.

Based on review of records, quality initiatives, quality data, and staff interviews, it was determined the hospital tracked metrics related to 72-hour Emergency Department (ED) Return Visits but failed to compile and utilize accurate aggregate data to monitor the safety and effectiveness of care due to a flawed collection process. Staff interviews and a review of records revealed staff re-opened the medical record of 1 of 25 patients returning to the Emergency Department (ED) within two hours of discharge and continued documentation of the return visit in the original visit record. Additionally, surveyors discovered the "2-hour process" was a routine hospital practice where patients discharged from the ED who again presented to the ED within two hours of that discharge, had only one visit record for what would be considered two separate ED visits.

Based on review of medical records, quality initiatives and meeting minutes, surveyors determined hospital Quality personnel identified inconsistencies in the Emergency Department (ED) process for handling "violent patients" who presented to the ED and were subsequently denied access prior to receiving triage, a medical screening exam (MSE), or any other clinical assessments.

In meeting minutes from the ED quality council in August, 2017, ED staff identified that the process of security personnel turning away patients presenting for treatment prior to any clinical assessment was problematic. An education plan was derived. However, no further documentation could be found indicating what, if anything, staff or hospital leadership did to remediate this practice. In addition, current QAPI data reviewed during the survey on 1/11/18 indicated no additional follow-up or data collection.

Based on interview and review of patient #1's emergency department (ED) record, it was determined that the hospital failed to keep accurate records for patient #1 and other patients presenting again within two hours of discharge from the ED.

On survey of 1/11/2018 at approximately 0930, a request to a Quality staff member for two ED records of the same-day belonging to patient #1 revealed in part, that patient #1 had only one record. This was due to an unwritten policy which instructed patient access staff to reopen an initial ED record of patients who return to the ED within 2 hours of ED discharge. Interview at 0930 revealed that, "The prior record (initial presentation) is reopened for continuity of care.

Interview at approximately 9:45 am with the Director of Patient Access revealed knowledge of the 2-hour rule, but identified that there was no written policy. Further, that when it is noted at the registrar that a patient had been seen 2-hours prior, the ED RN was to be notified. Interview at approximately 1030 with the Regional Medical Director for contracted ED providers revealed knowledge of the 2-hour rule and the statement that upon the second presentation, the expectation is that a provider enter an addendum progress note into the re-opened record.

Patient #1 was a young adult who presented to the ED in January 2018 at 1304 (12:04PM) via ambulance following a fall from a motorized bike, which resulted in striking a curb and an apparent minor head injury. On arrival, an MSE was conducted inclusive of Computed Tomography (CT) of the head. Following the MSE, patient #1 was found to be free of an emergency medical condition and was cleared for discharge.

Patient #1 was resistant to discharge and would not dress. Patient #1 was subsequently escorted from the hospital by security staff while still in a hospital gown on or about 2340 (11:40 PM), but was brought back via ambulance at 0013 (12:13AM). Ambulance documentation revealed patient #1's chief complaint was "I do not feel normal, and do not know what normal is." On arrival to the ED the second time, the initial ED record was reopened.