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Based on observation, interview and record review the facility failed to ensure that the Nurse call system was connected and in reach for three (#6, #7, #8) of four patients in the Emergency Department reviewed for patient safety out of a total sample of 10, resulting in the potential for adverse safety outcomes and missed care needs related to inability to contact nursing staff. Findings include:

On 8/19/20 at approximately 1350 the Emergency Department (ED) was toured with the ED Director Staff F, the ED Manager Staff G and the Director of Quality Staff A. Three of four ED patients observed and interviewed in ED patient rooms did not have access to the Nurse call system (call light).

Patient #6 did not have a call light in the room. Staff F said that it was not plugged into the wall outlet or present in the room. Staff F said that Nursing Staff disconnected the call light and removed it from the room if the patient was on suicide precautions. Patient #6 was alert and oriented and answered questions appropriately. Observation revealed numerous other cords within patient reach in Patient #6's room. Review of Patient #6's clinical record on 8/19/20 at 1400 revealed Patient #6 was a 23 year old male who presented to the ED on 8/19/20 for Tonsillitis and Nausea and Vomiting. When asked, Staff F said that Patient #6 was not on suicide precautions.

On 8/19/20 at approximately 1410 Patient #7 was observed and interviewed in the room. Patient #7 did not have a call light in reach. The call light was coiled up on the wall behind the bed and out of reach. On 8/19/20 at approximately 1420 review of Patient #7's clinical record revealed she was a 51 year old female who presented to the ED on 8/19/20 for difficulty breathing. Patient #7 was not on suicide precautions.

On 8/19/20 at approximately 1430 Patient #8 was observed in the room. Patient #8 did not have a call light in the room. On 8/19/20 at approximately 1435 Patient #8's clinical record was reviewed and revealed the following information: Patient #8 was a 76 year old female who presented to the ED on 8/19/20 for Chest Pain. Patient #8 was not on suicide precautions.

On 8/19/20 at approximately 1635 the chief Nursing Officer Staff B was interviewed about patient access to the Nurse call system in the ED and ability to contact a Nurse for care needs. Staff F said that she did not know if the facility had a policy regarding patient access to the Nurse call system but it was a standard of care for all patients in every unit to have a call light in reach. Staff B said that it could possibly increase the risk of falls and injury if patients had no way of calling the nurse for care needs such as toileting.

A policy was requested but not provided by survey exit.

Based on interview and record review the facility failed to ensure that medications were given as ordered by the physician for one (#4) of five patients reviewed for medication administration out of a total sample of 10, resulting in the potential for ineffective treatment of pain. Findings include:

On 8/20/20 at approximately 1500 Patient #4's clinical record was reviewed with Staff E. The following information was revealed:

Patient #4 was a 35 year old male who was admitted on 1/21/20 for surgery of the foot (bone removal) related to Osteomyelitis (infection of the bone and muscle). Diagnoses included Chronic Bilateral (both feet) Foot Osteomyelitis and a history of multiple surgeries for Osteomyelitis.

Review of Patient #4's medication orders revealed an order for Patient #4 to receive two tablets of Percocet (a pain reliever which contains acetaminophen, a non steroidal anti-inflammatory drug and oxycodone, a narcotic) every four hours as needed for pain.

Review of Patient #4's Medication Administration Record (MAR) from 1/21/20 through 1/28/20 revealed Patient #4 received only one Percocet tablet instead of the two ordered by the physician on two occasions.

On 1/22/20 at 2139 Patient #4 received one Percocet for a pain which the patient rated as 7 out of 10 (with 0 = no pain and 10 = worst pain possible).

On 1/23/20 at 0333 Patient #4 received one Percocet for pain which the patient rated as 6 out of 10.

There was no Nursing documentation to explain why one tablet was given instead of the two ordered on these two occasions. There was no documentation to indicate that the physician was contacted or informed regarding administration of one Percocet tablet instead of the two ordered. There was no Physician order to allow Patient #4 to receive one Percocet.

On 8/20/20 at approximately 1630 the Chief Nursing Officer (CNO) Staff B was interviewed regarding Patient #4. Staff B stated that there were no Standing Orders or facility policy allowing a nurse to administer a smaller dose than ordered by the physician. Staff B said that this was a medication administration error for Patient #4 to receive one Percocet instead of the two ordered.

Staff B stated that the facility was unaware of these medication errors for Patient #4 so they were not included on the log of medication errors for facility review.

A policy on Medication Administration was requested but not provided by survey exit.