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Based on interview, record review, document review, and review of the hospital's policies and procedures, the hospital failed to adopt and implement policies and procedures to ensure that admitted patients boarding in the emergency department (ED) received treatment according to the inpatient standards of care and failed to ensure adequate and qualified staff for the provision of emergency care.

Failure to adopt and implement policies and procedures to ensure that admitted patients boarding in the emergency department (ED) receive treatment according to the inpatient standards of care and failure to provide adequate and qualified staff for the delivery of emergency care places patients at risk for unsafe, incompetent, and poor quality emergency care.

Findings included:

1. Failure to adopt and implement policies and procedures to ensure staff completed and documented comprehensive admission assessments on 3 of 4 admitted patients boarding in the emergency department (ED) (Patient #1, #2 and #4).


2. Failure to adopt and implement policies and procedures to ensure staff completed and documented periodic reassessments on 4 of 4 admitted patients boarding in the ED (Patients #1, #2, #3, and #4).


3. Failure to adopt and implement policies and procedures to ensure staff completed and documented full sets of vital signs (including temperature, heart rate, respiratory rate, blood pressure, and oxygen saturation) on 4 of 4 admitted patients boarding in the ED (Patient #1, #2, #3, and #4).


4. Failure to adopt and implement policies and procedures to ensure staff completed and documented skin assessments and implementation of pressure injury prevention measures for 4 of 4 admitted patients boarding in the ED (Patient #1, #2, #3, and #4).


5. Failure to adopt and implement policies and procedures to ensure staff documented and updated nursing care plans for 4 of 4 admitted patients boarding in the ED (Patient #1, #2, #3, and #4).


6. Failure to adopt and implement policies and procedures to ensure staff documented and updated patient education for 4 of 4 admitted patients boarding in the ED (Patient #1, #2, #3, and #4).

Cross-reference A1104

7. Failure to adequately train and schedule sufficient qualified nursing staff to ensure admitted inpatients boarding in the emergency department (ED) received care according to inpatient standards for 4 of 4 patient records reviewed (Patients #1, #2, #3, and #4).

Cross-reference A1112

Due to the scope and severity of deficiences cited under 42 CFR 482.55, the Condition of Participation for Emergency Services was NOT MET.

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Based on observation, interview, and document review, the hospital failed to adopt and implement policies and procedures to ensure staff completed and documented comprehensive admission assessments for 3 of 4 admitted patients boarding in the emergency department (ED) (Patients #1, #2, and #4) (item #1), completed and documented periodic shift assessments for 4 of 4 admitted patients boarding in the ED (Patients #1, #2, #3, and #4) (item #2), completed and documented full sets of vital signs (including temperature, heart rate, respiratory rate, blood pressure) for 4 of 4 admitted patients boarding in the ED (Patients #1, #2, #3, and #4) (item #3), completed and documented skin assessments and pressure injury prevention measures for 4 of 4 admitted patients boarding in the ED (Patient #1, #2, #3, and #4) (item #4), initiated and updated nursing care plans for 4 of 4 admitted patients boarding in the ED (Patients #1, #2, #3, and #4) (item #5), and completed and documented nursing education for 4 of 4 admitted patients boarding in the ED (Patients #1, #2, #3, and #4) (item #6).

Failure to complete and document comprehensive admission assessments, periodic reassessments, vital sign assessments, skin assessments and pressure injury prevention measures, nursing care plans, and patient education risks patient harm from unrecognized or unmet care needs.

Findings included:

Item #1 - Comprehensive Assessments

1. Document review of the hospital's policy titled, "Patient Placement, Assessment Screening and Admission," policy ID 11108, effective 04/15/21, showed the following:

a. The RN will assess each patient's need for nursing care on admission to any area/department in which nurses provide care.

b. The RN will complete an initial focused assessment within 2 hours of the patient's arrival in the medical/surgical settings. This initial assessment will include the reason for admission and physical alterations occurring as a result of the current condition, vital signs, weight, medication history, allergies, and immunization status.

c. The remainder of the assessment must be completed within 12 hours of admission and should identify the patient's biophysical, psychosocial, environmental, educational, self-care, and discharge planning needs.

Document review of the hospital's policy titled, "Assessment Documentation for Hospitalized Patients," policy ID 14173, effective 04/07/22, with appendix "Medical Surgical Minimum Charting Standards," showed the following:

a. The RN will complete initial focused physical assessment on all acute care inpatients within 4 hours of arrival.

b. A comprehensive assessment of all systems will be completed within 12 hours of admission.

c. Focused or comprehensive assessments will be completed more frequently if a patient has a change of condition. The RN may include further details in a nursing note to better convey the changes of condition.

Review of the hospital document titled, "Boarded Patient in ED Checklist," no policy ID, dated 11/04/22, showed that the checklist served as a reminder for some of the most important items, but it did not include all the staff requirements and responsibilities when caring for boarders in the ED. Items listed in the checklist included:

a. Use the "Flowsheets tab" for most charting.

b. Move to an inpatient bed as soon as possible.

c. Complete a comprehensive Head to Toe assessment every 12 hours and a focused assessment as needed.

Patient #1

2. On 01/05/23 at 12:07 PM, Investigators #1 and #2, the Chief Nursing Officer (Staff #101), the Regional Director of Regulatory and Accreditation (Staff #103), and the Clinical Educator (Staff #102) reviewed the medical records for Patient #1, a 55-year-old adult with a history of alcoholism with ascites (a fluid collection in the abdomen), severe muscle atrophy (loss of muscle), and malnutrition. The review showed the following:

a. On 01/02/23 at 2:06 PM, Patient #1 arrived at the ED by ambulance with complaints of generalized weakness, dizziness, difficulty urinating, lower abdominal pain and low blood pressure. The patient was diagnosed with a urinary tract infection and ascites, and the ED provider consulted the hospitalist for admission.

b. On 01/02/23 at 11:55 PM, the hospitalist entered orders to admit Patient #1 under acute medical care inpatient status for monitoring and treatment of lactic acidosis, acute cystitis (bladder infection) with urinary retention, and alcoholic ascites.

c. Patient #1 remained in the ED and was still awaiting transfer to the inpatient medical unit at the time of the investigators' review. Nursing note documentation showed that staff completed a focused assessment on 01/03/23 at 07:00 AM, a period of 7 hours and 5 minutes following admission. The record showed no evidence that the patient received a comprehensive assessment at any time following admission.

d. Staff #101, Staff #102, and Staff #103 confirmed the investigators' findings of the late and missing assessments.

Patient #2

3. On 01/05/23 at 1:50 PM, Investigators #1 and #2, Staff #101, Staff #102, and Staff #103 reviewed the medical record of Patient #2, a 60-year-old adult with a history of diabetes, peripheral neuropathy, osteomyelitis (a bone infection), partial amputation of the left foot, and high blood pressure. The review showed the following:

a. On 01/03/23 at 1:09 PM, Patient #2 arrived at the ED for evaluation of a diabetic ulcer on the right heel. The ED work-up showed that the patient had suspected osteomyelitis and required admission for administration of intravenous (IV) antibiotics and surgical intervention.

b. On 01/03/23 at 9:36 PM, the provider entered orders to admit Patient #2 under acute medical inpatient status.

c. Patient #2 remained in the ED and was still awaiting transfer to the inpatient medical unit at the time of the investigators' review. Nursing note documentation showed that the RN completed a comprehensive head to toe physical assessment on 01/04/23 at 11:19 AM, 13 hours and 46 minutes from the time the patient was admitted, but the remainder of the admission assessment including psychosocial, environmental, educational, self-care, and discharge planning needs was incomplete.

d. Staff #101, Staff #102, and Staff #103 confirmed the investigators' finding that a comprehensive admission assessment of the patient was not completed within 12 hours, as required by hospital policy.

Patient #4

4. On 01/09/23 at 3:45 PM, Investigator #1, Investigator #2, Staff #101, Staff #103, the Chief Quality Officer (Staff #107), and the ED Manager (Staff #108) reviewed the medical record for Patient #4, a 75 year-old adult with a history of diabetes, high blood pressure, recent COVID 19 infection and knee surgery. The review showed the following:

a. On 11/03/22 at 4:22 PM, Patient #4 arrived at the ED with complaints of knee pain after a fall at home and shortness of breath.

b. On 11/04/22 at 4:10 PM, the provider entered orders to admit the patient to the hospital under acute inpatient medical status.

c. Document review showed that Patient #4 boarded and received inpatient care in the ED until transferring to the inpatient unit on 11/06/22 at 8:02 AM.

d. Review of nursing note documentation showed that on 11/06/22 at 8:08 AM, nursing staff completed Patient #4's comprehensive admission assessment, 39 hours and 58 minutes after the patient was admitted to the hospital.

e. Staff #101, Staff #103, Staff #107, and Staff #108 verified that a comprehensive admission assessment of the patient was not completed within 12 hours as required by hospital policy.

Item #2 - Periodic Reassessments

Findings included:

1. Document review of the hospital's policy titled, "Patient Placement, Assessment Screening and Admission," policy ID 11108, current effective date 04/15/21, showed the following that each patient will receive a focused reassessment periodically by a RN during hourly rounding, medication and care delivery, and with any change in condition. A comprehensive physical assessment will be completed and documented every 8/12-hour shift.

Review of the hospital document titled, "Boarded Patient in ED Checklist," no policy ID, dated 11/04/22, showed that the checklist served as a reminder for some of the most important items, but it did not include all the staff requirements and responsibilities when caring for boarders in the ED. Items listed in the checklist included:

a. Use the "Flowsheets tab" for most charting.

b. Move to an inpatient bed as soon as possible.

c. Complete a comprehensive Head to Toe assessment every 12 hours and a focused assessment as needed.

Review of the hospital's policy titled, "Triage and Assessment of Emergency Patients - SRH," policy ID 150792, current effective date 02/04/2021, showed the following:

a. Emergency Department reassessment is required for all patients. Reassessment may include but is not limited to: documentation of a patient's condition or change in condition, a patient's response to an intervention, and vital signs as appropriate to patient age and condition.

b. Based on patient's acuity, admitted patients boarding in the ED or ED patients with visits over 24 hours will be reassessed at a minimum with every change of shift from one RN to another or every eight (8) hours, unless ordered more frequently based on patient acuity.

Patient #1

2. On 01/05/23 at 12:07 PM, Investigators #1 and #2, Staff #101, Staff #102, and Staff #103 reviewed the medical records for Patient #1, a 55-year-old adult with a history of alcoholism with ascites, severe muscle atrophy, and malnutrition. The review showed the following:

a. On 01/02/23 at 2:06 PM, Patient #1 arrived at the ED by ambulance with complaints of generalized weakness, dizziness, difficulty urinating, lower abdominal pain, and low blood pressure. The patient was diagnosed with a urinary tract infection and ascites, and the ED provider consulted the hospitalist for admission.

b. On 01/02/23 at 11:55 PM, the hospitalist entered orders to admit Patient #1 under acute medical care inpatient status for monitoring and treatment of lactic acidosis, acute cystitis with urinary retention, and alcoholic ascites.

c. Patient #1 remained in the ED and was still awaiting transfer to the inpatient medical unit at the time of the investigators' review. Nursing note documentation showed that staff completed a focused assessment on 01/03/23 at 07:00 AM. The record showed no evidence that the patient received a shift assessment or reassessment following the initial focused assessment.

d. Staff #101, Staff #102, and Staff #103 confirmed the investigators' findings of the late and missing assessments.

Patient #2

3. On 01/05/23 at 1:50 PM, Investigators #1 and #2, Staff #101, Staff #102, and Staff #103 reviewed the medical record of Patient #2, a 60-year-old adult with a history of diabetes, peripheral neuropathy, osteomyelitis, partial amputation of the left foot, and high blood pressure. The review showed the following:

a. On 01/03/23 at 1:09 PM, Patient #2 arrived at the ED for evaluation of a diabetic ulcer on the right heel. The ED work-up showed that the patient had suspected osteomyelitis and required admission for administration of IV antibiotics and surgical intervention.

b. On 01/03/23 at 9:36 PM, the provider entered orders to admit Patient #2 under acute medical inpatient status.

c. Patient #2 remained in the ED and was still awaiting transfer to the inpatient medical unit at the time of the investigators' review. Nursing note documentation showed that the RN completed a comprehensive head to toe physical assessment on 01/04/23 at 11:19 AM. The record showed no evidence that the patient received a shift assessment or reassessment following the initial comprehensive assessment.

d. Staff #101, Staff #102, and Staff #103 confirmed the investigators' findings of the late and missing assessments.

Patient #3

4. On 01/05/23 at 3:22 PM, Investigator #1, Investigator #2, Staff #101, Staff #102, and Staff #103 reviewed the medical record for Patient #3, a 68-year-old adult with a history of diabetes, high blood pressure, chronic kidney disease and atrial fibrillation (an irregular and often rapid heart rhythm). The review showed the following:

a. On 12/15/22 at 1:52 PM, the patient arrived at the ED by ambulance for treatment after a fall at home and presented with a rapid heart rate and elevated blood sugar. The ED workup showed that the patient was positive for influenza A, sepsis (a serious infection in the blood stream), and a rapid, irregular, heart rate.

b. On 12/15/22 at 7:52 PM, the provider entered orders to admit Patient #3 under acute medical inpatient status.

c. Patient #3 remained in the ED awaiting transfer to the inpatient medical unit until their discharge home on 12/18/22 at 12:03 PM. Nursing documentation showed that the RN completed a comprehensive assessment on 12/15/22 at 8:00 PM. The record showed no shift assessment or reassessment was completed until 12/16/22 at 9:30 PM, a period of 25 hours and 30 minutes.

d. Staff #101, Staff #102, and Staff #103 confirmed the investigators' findings of the late and missing assessments.

Patient #4

5. On 01/09/23 at 3:45 PM, Investigator #1, Investigator #2, Staff #101, Staff #103, Staff #107, and Staff #108 reviewed the medical record for Patient #4, a 75-year-old adult with a history of diabetes, high blood pressure, recent COVID 19 infection and knee surgery. The review showed the following:

a. On 11/03/22 at 4:22 PM, Patient #4 arrived at the ED with complaints of knee pain after a fall at home and shortness of breath.

b. On 11/04/22 at 4:10 PM, the provider entered orders to admit the patient to the hospital under acute inpatient medical status.

c. Document review showed that Patient #4 boarded and received inpatient care in the ED until transferring to the inpatient unit on 11/06/22 at 8:02 AM.

d. Review of nursing note documentation showed that no shift assessments or reassessments were documented until 11/06/22 at 8:08 AM, a period of 39 hours and 58 minutes after the patient was admitted to the hospital.

e. Staff #101, Staff #103, Staff #107, and Staff #108 confirmed the investigators' findings of the late and missing assessments.

Item #3 - Vital Signs

Findings included:

1. Document review of the hospital's policy titled, "Assessment Documentation for Hospitalized Patients," policy ID 14173, current effective date 04/07/22 with appendix "Medical Surgical Minimum Charting Standards," showed the following:

a. Staff will complete vital signs including temperature, heart rate, respirations, blood pressure and oxygen saturation on non-telemetry patients every 8 hours, and on telemetry patients every 4 hours.

b. Increased frequency of documentation may be required based on patient condition or medications used.

Review of the hospital document titled, "Boarded Patient in ED Checklist," no policy ID, dated 11/04/22, showed that the checklist served as a reminder for some of the most important items, but it did not include all the staff requirements and responsibilities when caring for boarders in the ED. Items listed in the checklist included:

a. Use the "Flowsheets tab" for most charting.

b. Complete vital signs on non-telemetry patients every 8 hours and on telemetry patients every 4 hours.

Patient #1

2. On 01/05/23 at 12:07 PM, Investigators #1 and #2, Staff #101, Staff #102, and Staff #103 reviewed the medical records for Patient #1, a 55-year-old adult with a history of alcoholism with ascites, severe muscle atrophy, and malnutrition. The review showed the following:

a. On 01/02/23 at 2:06 PM, Patient #1 arrived at the ED by ambulance with complaints of generalized weakness, dizziness, difficulty urinating, lower abdominal pain, and low blood pressure. The patient was diagnosed with a urinary tract infection and ascites, and the ED provider consulted the hospitalist for admission.

b. On 01/02/23 at 11:55 PM, the hospitalist entered orders to admit Patient #1 under acute medical care inpatient status for monitoring and treatment of lactic acidosis, acute cystitis with urinary retention, and alcoholic ascites.

c. Patient #1 remained in the ED and was still awaiting transfer to the inpatient medical unit at the time of the investigators' review. Nursing note documentation showed that staff completed a full set of vital signs, including temperature, pulse, respirations, oxygen saturation, and blood pressure 2 of 37 entries between the time of admission and 01/05/23 at 1:00 PM, a period of 61 hours and 5 minutes.

d. Staff #101, Staff #102, and Staff #103 confirmed the investigators' findings of the missing vital signs.

Patient #2

3. On 01/05/23 at 1:50 PM, Investigators #1 and #2, Staff #101, Staff #102, and Staff #103 reviewed the medical record of Patient #2, a 60-year-old adult with a history of diabetes, peripheral neuropathy, osteomyelitis, partial amputation of the left foot, and high blood pressure. The review showed the following:

a. On 01/03/23 at 1:09 PM, Patient #2 arrived at the ED for evaluation of a diabetic ulcer on the right heel. The ED work-up showed that the patient had suspected osteomyelitis and required admission for administration of IV antibiotics and surgical intervention.

b. On 01/03/23 at 9:36 PM, the provider entered orders to admit Patient #2 under acute medical inpatient status.

c. Patient #2 remained in the ED and was still awaiting transfer to the inpatient medical unit at the time of the investigators' review. Nursing note documentation showed that staff documented a full set of vital signs, including temperature, pulse, respirations, oxygen saturation, and blood pressure 1 of 15 entries between the time of admission and 01/05/23 at 1:50 PM, a period of 40 hours and 14 minutes.

d. Staff #101, Staff #102, and Staff #103 confirmed the investigators' findings of the missing vital signs.

Patient #3

4. On 01/05/23 at 3:22 PM, Investigator #1, Investigator #2, Staff #101, Staff #102, and Staff #103 reviewed the medical record for Patient #3, a 68-year-old adult with a history of diabetes, high blood pressure, chronic kidney disease, and atrial fibrillation. The review showed the following:

a. On 12/15/22 at 1:52 PM, the patient arrived at the ED by ambulance for treatment after a fall at home and presented with a rapid heart rate and elevated blood sugar. The ED workup showed that the patient was positive for influenza A, sepsis, and a rapid, irregular, heart rate.

b. On 12/15/22 at 7:52 PM, the provider entered orders to admit Patient #3 under acute medical inpatient status.

c. Patient #3 remained in the ED awaiting transfer to the inpatient medical unit until their discharge home on 12/18/22 at 12:03 PM. Nursing documentation showed that staff documented a full set of vital signs, including temperature, pulse, respirations, oxygen saturation, and blood pressure 10 of 20 entries between the time of admission and 12/18/22 at 11:35 AM, a period of 63 hours and 43 minutes.

d. Staff #101, Staff #102, and Staff #103 confirmed the investigators' findings of the missing vital signs.

Patient #4

5. On 01/09/23 at 3:45 PM, Investigator #1, Investigator #2, Staff #101, Staff #103, Staff #107, and Staff #108 reviewed the medical record for Patient #4, a 75-year-old adult with a history of diabetes, high blood pressure, recent COVID 19 infection and knee surgery. The review showed the following:

a. On 11/03/22 at 4:22 PM, Patient #4 arrived at the ED with complaints of knee pain after a fall at home and shortness of breath.

b. On 11/04/22 at 4:10 PM, the provider entered orders to admit the patient to the hospital under acute inpatient medical status.

c. Document review showed that Patient #4 boarded and received inpatient care in the ED until transferring to the inpatient unit on 11/06/22 at 8:02 AM.

d. Review of nursing note documentation showed that staff documented a complete set of vital signs, including temperature, pulse, respirations, oxygen saturation, and blood pressure 0 of 9 entries between the time of admission and the time the patient was transferred to the inpatient unit, a period of 39 hours and 52 minutes.

e. Staff #101, Staff #103, Staff #107, and Staff #108 confirmed the investigators' findings of the missing vital signs.

Item #4 - Pressure Injury Prevention

Findings included:

1. Document review of the hospital's policy titled, "Assessment Documentation for Hospitalized Patients," policy ID 14173, effective 04/07/22, with appendix "Medical Surgical Minimum Charting Standards," showed the following:

a. A 2-RN skin assessment will be completed within 4 hours of admission.

b. Intake and output will be documented at least once a shift, or more frequently if ordered, as close to real time as possible.

c. Pressure relieving interventions will be documented every shift or more frequently if indicated.

Review of the hospital document titled, "Boarded Patient in ED Checklist," no policy ID, dated 11/04/22, showed that the checklist served as a reminder for some of the most important items, but it did not include all the staff requirements and responsibilities when caring for boarders in the ED. Items listed in the checklist included:

a. Use the "Flowsheets tab" for most charting.

b. Move to an inpatient bed as soon as possible.

c. A 2 RN skin assessment will be documented within 4 hours after admission.

d. A Braden score will be documented every shift.

e. Provide meal trays when delivered.

f. Turn patients position every 2 hours.

Document review of the hospital's policy titled, "Inpatient Pressure Injury Prevention," policy ID 13208, current effective date 12/22/2021, showed the following:

a. Upon inpatient admission, all patients will have a full body two Registered Nurse (RN) skin assessment within 4 hours of admission. A Braden Pressure Injury Risk Assessment (Braden) completed within 8 hours. If any skin breakdown is noted, a photo of the area will be taken and uploaded into the medical record.

b. All patients will have the Braden Score or Braden Q re-assessed twice a day and documented in the patient's medical record.

c. RN's will be prompted to initiate the "Pressure Injury Prevention Nurse Protocol" in the electronic medical record if:

i. The Braden Score is 18 or less,

ii. The patient has a pressure injury on admission,

iii. Patient has a history of a pressure injury,

iv. Patient is exhibiting poor perfusion, blood pressure equal or less than 100/55,

v. Body Mass Index (BMI) <22 or >40,

vi. Patient has a diagnosis of COVID 19,

vii. Per nursing discretion

d. When the RN assessment indicates, initiate the Pressure Injury Prevention Nurse Protocol in the electronic medical record or if a patient develops a pressure injury after admission the RN will be advised to:

i. Initiate nursing care plan

ii. Order a Dietician consult & correlating labs (albumin, prealbumin)

iii. Place a Waffle overlay on patient bed and chair.

iv. Place a bordered foam dressing to affected or potentially affected area such as pressure points or under medical devices.

v. Order to be up in the chair three times a day with Waffle chair pad.

vi. Order ambulation three times a day

vii. Initiate and document every two hour repositioning

viii. Document, monitor, and manage moisture every 6 hours and as needed.

ix. If patient has an existing pressure injury take photo, document present on arrival, and document skin assessment under LDA "Pressure Injury" in the flowsheet.

Patient #1

2. On 01/05/23 at 12:07 PM, Investigators #1 and #2, Staff #101, Staff #102, and Staff #103 reviewed the medical records for Patient #1, a 55-year-old adult with a history of alcoholism with ascites, severe muscle atrophy, and malnutrition. The review showed the following:

a. On 01/02/23 at 2:06 PM, Patient #1 arrived at the ED by ambulance with complaints of generalized weakness, dizziness, difficulty urinating, lower abdominal pain, and low blood pressure. The patient was diagnosed with a urinary tract infection and ascites, and the ED provider consulted the hospitalist for admission.

b. On 01/02/23 at 11:55 PM, the hospitalist entered orders to admit Patient #1 under acute medical care inpatient status for monitoring and treatment of lactic acidosis, acute cystitis with urinary retention, and alcoholic ascites.

c. On 01/02/23 at 8:00 PM, a blanchable pressure ulcer to the coccyx (tailbone) and middle thoracic (mid-back) right side of spine was noted in the nurses' notes. At that time, bordered foam dressings were applied to the areas.

d. On 01/03/23 at 6:28 AM, an end-of-shift nurses' note stated that the patient was being turned every 2 hours.

e. On 01/03/23 at 12:46 AM, provider note documentation showed that Patient #1 appeared malnourished and cachectic, had a low body mass index of 18.65, and had two stage 1 pressure ulcers (unopened wounds affecting the upper layer of skin) on the sacrum (bottom of the spine) and mid-thoracic spine.

f. On 01/03/23 at 5:00 PM, 43 hours following admission, nursing flowsheet documentation showed that Patient #1 had a Braden score of 14 and was at "moderate risk" of developing pressure ulcers. At the time of the review, the medical record contained no other documented Braden assessments.

g. On 01/04/23 at 9:55 AM, nursing orders were placed to reposition the patient, monitor and manage moisture, place bordered foam dressing, and place a waffle overlay on the patient bed, a period of 34 hours after admission time.

h. Review of nursing notes showed that staff failed to document a 2-RN skin assessment within 4 hours of admission, initiate a nursing care plan for skin breakdown, initiate a nutrition consult, place a waffle overlay matter on the bed and chair, document patient activity including turning every 2 hours, sitting in a chair 3 times a day, or walking in the hallway 3 times a day, document measures to manage moisture, and document nutritional or oral intake as required by hospital policy.

Patient #2

4. On 01/05/23 at 1:50 PM, Investigators #1 and Investigator #2, Staff #101, Staff #102, and Staff #103 reviewed the medical record of Patient #2, a 60-year-old adult with a history of diabetes, peripheral neuropathy, osteomyelitis, partial amputation of the left foot, and high blood pressure. The review showed the following:

a. On 01/03/23 at 1:09 PM, Patient #2 arrived at the ED for evaluation of a diabetic ulcer on the right heel. The ED work-up showed that the patient had suspected osteomyelitis and required admission for administration of IV antibiotics and surgical intervention.

b. On 01/03/23 at 9:36 PM, the provider entered orders to admit Patient #2 under acute medical inpatient status.

c. On 01/03/23 at 9:11 PM, the physician documented a 2 cm thick ulceration to the right heel in the History and Physical note.

d. Patient #2 remained in the ED and was still awaiting transfer to the inpatient medical unit at the time of the investigators' review. Nursing note documentation showed that nursing staff failed to document a wound assessment, Braden score, nutritional intake, and repositioning of the patient for the entire time of admission, a period of 40 hours and 14 minutes.

e. Staff #101, Staff #102, and Staff #103 confirmed the investigators' findings of the missing wound assessments, Braden scores, nutritional intake, and repositioning of the patient.

Patient #3

5. On 01/05/23 at 3:22 PM, Investigator #1, Investigator #2, Staff #101, Staff #102, and Staff #103 reviewed the medical record for Patient #3, a 68-year-old adult with a history of diabetes, high blood pressure, chronic kidney disease, and atrial fibrillation. The review showed the following:

a. On 12/15/22 at 1:52 PM, the patient arrived at the ED by ambulance for treatment after a fall at home and presented with a rapid heart rate and elevated blood sugar. The ED workup showed that the patient was positive for influenza A, sepsis, and a rapid, irregular, heart rate.

b. On 12/15/22 at 7:52 PM, the provider entered orders to admit Patient #3 under acute medical inpatient status.

c. On 12/16/22 at 5:00 AM, the nursing note documentation showed that the patient was incontinent of urine but refusing to change his clothes.

d. On 12/17/22 at 7:45 AM, nursing note documentation showed an update to the Care Plan to include impaired skin integrity.

e. Patient #3 boarded in the ED for 64 hours and 11 minutes, until their discharge home on 12/18/22 at 12:03 PM.

f. Nursing documentation showed no evidence that staff completed a 2-RN skin assessment within 4 hours of admission, placed a waffle overlay mattress on the bed and chair, monitored patient activity, implemented measures to manage moisture, or monitored the patient's nutritional or oral intake as required by hospital policy. Review of the nursing documentation showed no evidence of nutritional intake for the duration of the patient's admission.

g. Staff #101, Staff #102, and Staff #103 confirmed the investigators' findings of the mission nutritional intake.

Patient #4

6. On 01/09/23 at 3:45 PM, Investigator #1, Investigator #2, Staff #101, Staff #103, Staff #107, and Staff #108 reviewed the medical record for Patient #4, a 75-year-old adult with a history of diabetes, high blood pressure, recent COVID 19 infection and knee surgery. The review showed the following:

a. On 11/03/22 at 4:22 PM, Patient #4 arrived at the ED with complaints of knee pain after a fall at home and shortness of breath.

b. On 11/04/22 at 4:10 PM, the provider entered orders to admit the patient to the hospital under acute inpatient medical status.

c. Document review showed that Patient #4 boarded and received inpatient care in the ED until transferring to the inpatient unit on 11/06/22 at 8:02 AM.

d. Review of nursing note documentation showed that nursing staff failed to perform a 2-person skin assessment within 4 hours of admission, complete a Braden assessment upon admission and every shift, initiate a nursing care plan for impaired skin integrity, or document any interventions to prevent injury including frequent repositioning and use of waffle overlay mattress, monitoring activity and nutritional intake at any time while the patient was boarding in the ED.

e. On 11/06/22 at 8:08 AM, staff documented a 2-person skin assessment showing that the patient had a reddened perineum and testicles, a Braden score of 18 (indicating mild pressure injury risk), and nutritional intake, a period of 39 hours and 58 minutes after admission time.

f. Staff #101, Staff #103, Staff #107, and Staff #108 confirmed the investigators' findings that multiple skin assessments, patient positioning, wound assessments, and nutritional intake were missing from the record and the Pressure Injury Prevention orders were delayed.

Item #5 Nursing Care Plans

Findings included:

1. Document review of the hospital's policy titled, "Patient Placement, Assessment Screening and Admission," policy ID 11108, effective 04/15/21, showed that the RN will assess each patient's need for nursing care on admission to any area/department in which nurses provide care.

Review of the hospital document, "Patient Placement, Assessment Screening and Admission," policy ID 11108, effective 04/15/21, showed that each patient's need for care or treatment will be analyzed and a treatment plan appropriate to the identified needs developed. Patient care or treatment will be consistent with the identified treatment plan. The document showed that the RN will initiate a plan of care for all admitted patients within 12 hours of admission.

Review of the hospital document titled, "Assessment Documentation for Hospitalized Patients," policy ID 14173, effective 04/07/22, showed that every inpatient will have a plan of care appropriate to their needs initiated within 12 hours of admission. The Care Plan is individualized, based on the patient's admitting diagnosis and includes the patient and family when available. The document showed that the RN will review, update, and document on the Care Plan every shift. Care Plan documentation will include updates on problems found during admission or reassessment and interventions to address pertinent problems or care provided.

Review of the hospital document titled, "Boarded Patient in ED Checklist," no policy ID number, dated 11/04/22, showed that the checklist served as a reminder of "some of the most important items" for staff to complete, but it did not include all responsibilities and care needed. The review showed that the list did not include initiating and updating nursing care plans.

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Based on observation, interview, and document review, the hospital failed to adequately train and schedule sufficient qualified nursing staff to ensure admitted inpatients boarding in the emergency department (ED) received care according to inpatient standards for 4 of 4 patient records reviewed (Patients #1, #2, #3, and #4) (item #1) and failed to provide adequate staff to ensure that patients presenting seeking emergency medical care in the ED received care according to hospital policies and standards (Patient #5) (item #2).

Failure to ensure that admitted inpatients boarding in the ED receive care according to inpatient standards and failure to provide adequate staff to ensure that all patients seeking emergency services receive care according to hospital policies and standards places patients at risk for harm from inadequate or improper care.

Item #1 Admitted ED Boarders

Findings included:

1. Document review of the hospital's policy titled, "Triage and Assessment of Emergency Patients - SRH," policy ID 150792, current effective date 02/04/2021, showed that admitted patients boarding in the ED or ED patients with visits over 24 hours will be reassessed at a minimum with every change of shift from one RN to another or every eight (8) hours, unless ordered more frequently based on patient acuity.

Document review of the hospital's policy titled, "Assessment Documentation for Hospitalized Patients," policy ID 14173, effective 04/07/22, with appendix "Medical Surgical Minimum Charting Standards," showed the following:

a. Upon admission, staff will complete and document a focused assessment, vital signs, and a 2-RN skin assessment within 4 hours and a comprehensive admission assessment, a nursing care plan and patient education within 12 hours.

b. Every shift, staff will complete and document a comprehensive assessment every 12 hours, focused assessments as needed, Braden score, patient education and a review and update of the nursing care plan.

c. Staff will complete and document vital signs every 8 hours for non-telemetry and every 4 hours for telemetry patients, document intake and output at least once a shift or more frequently if ordered, and activities of daily living provided.

d. Pressure relieving interventions will be documented every shift or more frequently when indicated.

2. On 01/05/23 at 9:00 AM and 01/05/23 at 4:40 PM, Investigators #1 and #2 interviewed two registered nurses in the ED (Staff #105 and Staff #106). The interviews showed that all ED staff were expected to provide inpatient care for ED boarders. Staff #105 and Staff #106 stated that they did not receive any formal training for inpatient documentation requirements. Staff #106 stated that the ED staff received an email with documentation tips for inpatients a couple of months ago, but otherwise, staff had to seek out information on their own. Staff #106 stated that ED staff did not have the same view of the electronic medical record (EMR) as inpatient nurses, and when documenting care, it was quicker for ED staff to enter a nursing note rather than document on the correct flowsheet. Staff #105 and #106 stated that they thought patients were receiving good care in the ED, but staff were not documenting it because they were too busy and did not have time. Staff #105 stated that the ED manager has increased the number of staff during the shift, but the ED patient volumes have continued to increase.

3. On 01/09/23 at 1:41 PM, an interview with the ED Nurse Manager (Staff #108) showed that ED management emailed nursing staff a tip sheet with instructions for documenting care of ED boarders. Staff #108 stated that staff were instructed to use the flowsheet tab to document care. Staff #108 confirmed that the ED has doubled the budget for staffing in the past 6 months, but the ED has been unable to move patients to the inpatient units once admission orders are entered, causing staff to care for both the increasing number of ED patients and the inpatient boarders. Staff #108 stated that when available, they will have staff from inpatient areas float to the ED to assist with boarders, but that is infrequent since the units do not have additional staff to spare.

4. Investigators reviewed the medical records of 4 admitted patients boarding and receiving inpatient care in the ED. The review showed the following:

a. Staff failed to document complete admission assessments according to hospital policy for 3 of 4 patient records reviewed (Patients #1, #2, and #4).

b. Staff failed to document shift assessments according to hospital policy for 4 of 4 patient records reviewed (Patients #1, #2, #3, and #4).

c. Staff failed to document vital signs according to hospital policy for 4 of 4 patient records reviewed (Patients #1, #2, #3, and #4).

d. Staff failed to document any meals eaten or oral intake according to hospital policy for 4 of 4 patient records reviewed.

e. Staff failed to document Braden scores, skin assessments and pressure relieving interventions according to hospital policy for 4 of 4 patient records reviewed (Patients #1, #2, #3, and #4).

f. Staff failed to document nursing care plans according to hospital policy for 4 of 4 patient records reviewed (Patients #1, #2, #3, and #4).

g. Staff failed to document patient education according to hospital policy for 4 of 4 patient records reviewed.

5. On 01/09/23 at 5:00 PM the Chief Nursing Officer (Staff #101) and the Regional Director of Quality (Staff #103) confirmed the investigators' findings of the missing documentation. Staff #101 and #103 stated that the hospital has taken multiple steps to increase staffing throughout the hospital, including the ED. Staff #101 stated that the hospital has been working with agencies to hire temporary workers, increased the premium pay for staff picking up extra shifts, worked with the union to change the float language and cross train staff to different nursing units, and started a labor pool for non-nursing staff to assist with non-patient care related activities. The hospital recently contacted the Snohomish County Medical Corps to apply for volunteer assistance. When extra staff are available, Staff #101 and #103 reported that the hospital will open up an 8 bed acute medical inpatient overflow unit to help move patients out of the ED and into an inpatient area. Staff #101 and #103 stated that the hospital has been operating in crisis mode for months, but it remained the hospital expectation that admitted patients in the ED receive the same standard of care as patients admitted to the inpatient units.

Item #2 Emergency Medical Care

Findings included:

1. Document review of the hospital policy titled, "Emergency Department Structure Standards - CVH," policy ID 155052, effective 02/15/22, showed the following:

a. The ED contains 16 beds, two triage rooms, and a waiting room outside the department, across from registration. The ED averages 20,000 patients per year.

b. All patients presenting for care in the ED are seen, and initial treatment is provided based on immediate need.

c. Nursing is responsible for keeping the medical staff informed about patient status, implementing medical direction promptly and accurately, and facilitating communication between the provider, patient/family members and support services.

d. All triage nurses (RNs) assess all patients for triage upon or shortly after arrival to the ED. When the demands for beds is beyond the capacity, patients triaged as level IV or V are seen in order of arrival, and patients triaged as levels I, II, and III are seen based on acuity and severity of illness. Additional gurneys and wheelchairs are used, and patients may be held and treated in the open area of the department.

e. Patients are discharged as soon as all care is rendered and the patient's condition is stable. Admitted patients will remain in the ED until a bed becomes available, is transferred to a higher level of care, or is stabilized enough for discharge.

Document review of the hospital policy, "Emergency Department Triage SOP - CVH," policy ID 153832, effective 01/03/23, showed that when triaging the main waiting room area, the triage RN should greet, assess, and directly escort patients to the triage room. When all ED rooms and treatment spaces are full, the triage nurse shall remain available to assess and prioritize patients in the waiting room. This includes reassessment and vital signs as appropriate to the emergency severity index (ESI) level of the patient.

Document review of the hospital policy titled, ''Triage and Assessment of Emergency Patients - SRH," policy ID 150792, effective 02/04/21, showed the following:

a. When no treatment space is available in the ED, the triage nurse will prioritize patient flow, re-evaluating and reprioritizing patients as appropriate. This may be a conversation and visual evaluation and include vital signs.

b. If there are no patients presenting to triage, the triage RN may assist other nurses but should not take a patient assignment that will prevent their return to the triage space and duties.

c. ED reassessment is required for all patients and may include documentation of a change in condition, a response to an intervention, and vital signs. A documented reassessment should occur when a significant change in symptoms or condition occurs, after every intervention or treatment, and at discharge, transfer, or admission.

2. Review of the hospital documents titled, "Monthly ED Visits 11/20 - 11/22" and "Monthly Left Without Being Seen Rate 11/20 to 11/22," showed there was a total of 22,015 patient ED visits between 12/21 and 11/22. The reports showed that the hospital's goal for patients that left without being seen (LWBS) was a rate of 2%, or less. The LWBS average for 12/21 to 11/22 was 12.5% and a maximum LWBS rate of 30% from 06/22 to 07/22.

3. On 01/05/23 at 9:00 AM, investigators interviewed the ED charge nurse (Staff #105). Staff #105 stated there were 9 inpatient boarders (admitted patients waiting for transfer to inpatient unit beds), 3 patients waiting for transfer to other facilities, and 13 patients waiting for triage, assessment, and discharge/disposition. The interview showed that when all ED rooms were full, the triage RN was assigned to monitor the patients in the lobby. Staff #105 stated that within the last 6 months, the ED manager has increased the number of staff on shift to match the increase in patient volumes, but the high volume of ED boarders makes it difficult to staff the department adequately and provide timely treatment to patients seeking emergency medical care.

4. On 01/05/23 at 8:00 AM, investigators observed a patient receiving intravenous (IV) fluids sitting in the hospital lobby next to the gift shop (Patient #5). Patient #5 was located on the opposite side of the ED waiting room and out of the line of sight and earshot of the ED triage and registration staff.

5. On 01/05/23 at 11:30 AM, Investigators #1 and #2 reviewed the medical record of Patient #5 with the clinical nurse educator (Staff #104), the Chief Nursing Officer (Staff #101), and the Regional Director of Quality (Staff #103). The review showed the following:

a. On 01/04/23, Patient #5 visited the ED with complaints of uncontrolled blood sugars, abdominal pain, nausea, and vomiting. He was evaluated and discharged the same day but returned for similar complaints at 6:03 AM the next day. The review showed that nursing staff obtained vital signs, collected bloodwork and initiated IV fluids within 25 minutes of Patient #5's arrival. Following the patients medical screening exam, nursing staff administered IV medications for heartburn at 8:19 AM and nausea at 8:39 AM. The document showed that at 8:23 AM the provider ordered 8 units of regular insulin subcutaneously for a blood sugar of 398 and recheck the blood sugar in one hour, but investigators found no evidence that staff administered the insulin as ordered. Staff #104 confirmed that nursing staff did not administer the patient's insulin as ordered.

Nursing note documentation showed that at 10:00 AM, Patient #5's spouse arrived, requested that staff remove the patient's IV, and stated they would be going elsewhere for care. At 10:20 AM, the RN (Staff #108) documented that Patient #5 left with family, and the record showed patient was "dismissed" and "left against medical advice." Provider note documentation showed that the patient "eloped." Investigators found no documentation that staff notified the provider of Patient #5's intent to leave AMA or that the patient received information or understood the risks of leaving AMA. Staff #101 and #103 stated that the RN may have provided the information, but she may not have had time to document it yet.

6. On 01/09/23 at 1:41 PM, Investigators #1 and #2 reviewed Patient #5's medical record with the ED nurse manager (Staff #108), Staff #101, and Staff #103. The review showed no documentation that the patient signed out AMA or refused to sign AMA paperwork. Staff #108 confirmed that the triage RN is responsible for observing patients in the lobby and stated that she was working as the triage RN the morning of 01/05/23. Staff #108 stated that she removed Patient #5's IV at the request of his wife, confirmed that she was aware of the patient's intent to leave and seek treatment at another hospital, and stated that she did not notify the provider or complete any AMA paperwork. Staff #108 was unable to verbalize the difference between patients eloping and patients leaving AMA.
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