HospitalInspections.org

The Condition of Participation: Governing Body was out of compliance.

Findings included:

Based on records reviewed and interviews, the Hospital failed to ensure an effective Governing Body was responsible for the conduct of the Hospital., when the Hospital failed to ensure Nursing Services, Emergency Services, and Quality Assessment and Performance Improvement (QAPI) requirements were met.

Cross Reference:
482.12(f): Governing Body: Emergency Services (0091)
482.21(a), (c)(2), (e)(3): Quality Assessment and Performance Improvement: Patient Safety (0286)
482.23(b): Nursing Services: Staffing and Delivery of Care (0392)
482.23(b)(6): Nursing Services: Supervision of Contract Staff (0398)
482.55(a)(2): Emergency Services: Integration of Emergency Services (1103)
482.55(a)(3): Emergency Services: Emergency Services Policies (1104)

Based on records reviewed and interviews the Hospital's Governing Body failed to ensure emergency service requirements were met.

Findings included:

The Hospital's Quality and Safety Plan, dated 2023-2024, indicated the Board of Directors, as defined in the Hospital Bylaw actively engages in oversight and holds overall responsibility and accountability for of system quality, safety and regulatory compliance, while holding management accountable for the articulation and attainment of quality, safety, and regulatory goals.

Further review of the Quality and Safety Plan, indicated the Quality and Safety Committee of the Board of Directors (QCBD) holds primary responsibility, as delegated from the Board, for the functioning of the quality assessment and performance improvement program, receives reports and evaluates effectiveness of the various medical staff and Hospital committees with primary responsibility for the oversight of quality monitoring. The QCBD was responsible in assuring all actions are completed in a timely manner and sustained to ensure no recurrence of the event reported.

The Governing Body failed to ensure the Hospital operations of the Quality Assessment and Performance Improvement (QAPI) program activities to track and analyze patient adverse events.

Cross Reference:
482.21(a), (c)(2), (e)(3): Quality Assessment and Performance Improvement: Patient Safety (0286)
482.23(b): Nursing Services: Staffing and Delivery of Care (0392)
482.23(b)(6): Nursing Services: Supervision of Contract Staff (0398)
482.55(a)(2): Emergency Services: Integration of Emergency Services (1103)
482.55(a)(3): Emergency Services: Emergency Services Policies (1104)

The Condition of Participation: Quality Assessment and Performance Improvement Program (QAPI) was out of compliance.

Findings included:

Based on records reviewed and interviews, for four of 10 sampled patients (Patient #1, #2, #3, and #4), the Hospital failed to ensure the Quality Assessment and Improvement Program (QAPI) implemented and maintained an effective, ongoing, hospital-wide, data-driven quality assessment, and performance improvement program to implement preventative actions in response to preventable adverse patient events.

Cross Reference:
482.21(a), (c)(2), (e)(3): Quality Assessment and Performance Improvement: Patient Safety (0286)

Based on records reviewed and interviews, for four of 10 sampled patients (Patient #1, #2, #3, and #4), the Hospital failed to ensure the Quality Assessment and Improvement Program (QAPI) implemented and maintained an effective, ongoing, hospital-wide, data-driven quality assessment, and performance improvement program to implement preventative actions in response to preventable adverse patient events.

Findings include:

The Hospital ' s Policy titled, Incident Reports: Sentinel Events, dated 5/10/22, indicated that the Hospital systems identify, report, investigate, develop/implement corrective actions, and disclose to patients and/or family in a timely fashion and responded to serious events. The Policy defined a sentinel event as a patient safety event that reaches a patient and results in death, severe harm regardless of duration, and permanent harm.

1. The Hospital's Policy titled Emergency Department (ED) Nursing Triage, dated 6/14/22, defined triage as the process whereby emergency department patients with the highest acuity are treated first in the accordance with resource demands. The Policy indicated patients were triaged into one of the five Emergency Severity Index (ESI) levels: Level one patients required immediate evaluation and treatment with the use of many resources, level two patients required evaluation and treatment as soon as possible with reassessment as needed requiring multiple resources, level three, four, and five level were stable patients could wait for evaluation and treatment requiring multiple diagnostic and therapeutic resources.

The Hospital's Policy titled Patient Assessment, reassessment, and documentation of care in the Emergency Department, dated 6/14/22, indicated that patient vitals (pulse rate, respiratory rate, blood pressure, temperature, oxygen saturation, and pain assessment) were repeated a minimum of every four hours for active ED patients. The Policy indicated the reassessment of active patients in the ED waiting room was the responsibility of the triage nurse and all assessments would be documented in the medical record.

Review of the Hospital's Incident Report indicated that on 9/11/2023, at 9:37 A.M., Patient #1 presented to the Hospital's ED via emergency medical services with complaints of nausea, vomiting and right flank pain. Around 9:49 A.M., the Triage Nurse assessed Patient #1 as an ESI level three. Patient #1 was orally administered four milligrams (mg) of Zofran (anti-nausea medication) and diagnostic labs were ordered. Patient #1 was placed back in the ED waiting room until an ED bed became available for a full medical evaluation.

The Hospital ' s Incident Report indicated that around 6:19 P.M., a Triage Nurse reported attempting to call out to Patient #1 for an evaluation followed be calling Patient #1's cell phone, both without a response. At 7:40 P.M., the Triage Nurse assumed that Patient #1 eloped from the ED waiting room and his/her disposition status in the medical record was documented as eloped.

The Hospital's Incident Report indicated that around 8:30 P.M., Patient #1's friend presented to the ED and noticed Patient #1 was seated in the ED waiting room and was weak and minimally responsive. Patient #1's friend alerted the Triage Nurse and Patient #1 was immediately brought into the ED and was intubated and admitted to the intensive care unit.

The Hospital's Adverse Outcome/Root Cause Analysis (RCA)'s meeting minutes, dated 9/14/23, indicated the Triage Nurse assessed and documented Patient #1 as an ESI level three, but the RCA determined Patient #1 should have been an ESI level two; therefore, nursing staff would be re-educated on patient symptoms and the ESI Calculator.

The RCA's meeting minutes, dated 9/21/23, indicated that during a meeting with Risk Management, the Triage Nurse said she did not re-assess Patient #1 in the ED waiting room because she was extremely busy and was behind, trying to catch up on [ED] patients.

Review of the Hospital's Immediate Action Plan for Patient #1's adverse event on 9/11/23, indicated the following actions would be completed by 10/2/23:
- All triage nurses would be re-educated on the Hospital's Nursing Triage policy.
- Audits for appropriate ESI and vital reassessments would be completed to monitor compliance.
- Implemented an ED tech in the ED waiting room to assist and document patient revitalizing, rounding, and communicating with the Triage Nurse.

During an interview on 9/26/23 at 1:56 P.M., the Senior Director of Quality and Behavioral Health Services said she was unsure if the Triage Nurse had notified nursing leadership on 9/11/23, when she was busy and unable to reassess Patient #1 in the ED waiting room. The Director said there was no documentation to support the hospital developed, implemented, or monitored re-education on calling a Code Help and/or reporting the inability to care for existing patients because the acuity impeded the provision of safe patient care.

The Director said the Hospital's Immediate Action Plan for Patient #1's adverse event on 9/11/23, included sending an email re-educating triage nurses and ED techs assigned to the ED waiting room; however, there was no documentation to support the Hospital was tracking who opened and/or reviewed the email with the details of the Action Plan.


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2. Patient #4 presented to the ED on 7/20/23, with complaints of shortness of breath and tachycardia (elevated heart rate). Patient #4 was triaged by the Triage Nurse at 9:14 A.M. and his/her heart rate was elevated at 131 (normal range is 60-100 beats per minute). Patient #4 was assigned as an ESI level 2 status and brought back from triage to the ED treatment area. At approximately 1:30 P.M. (more than 4 hours later), Patient #4 was found in the hall with facial cyanosis (a bluish discoloration of skin resulting from inadequate oxygenation of blood) and bradycardic (low heart rate). Patient #4 was unresponsive and assisted with breathing via Bag-valve-mask (a hand-held device used to provide positive pressure ventilation to patients who are not breathing or are not breathing adequately). Patient #4 was brought into an ED room and at approximately 1:47 P.M., Patient #4 lost his/her pulse and cardiopulmonary resuscitation (CPR) was initiated.

Review of the Hospital Adverse Outcome/ Root Cause Analysis (RCA), undated, indicated that on 7/20/23, Patient #4 was not assigned a nurse while in the hallway for four hours when he/she coded. The RCA failed to indicate any corrective actions implemented or any re-education to prevent a like occurrence.

During an interview on 9/28/23, at 10:43 A.M., Registered Nurse (RN) #1 said the Triage Nurse called her with concerns about Patient #4 on 7/20/23, and RN#1 said it was okay to send Patient #4 back to a bed in the ED treatment area. RN#1 said Patient #4 was never tracked and her status wasn't changed in the ED tracker, so a Registered Nurse was not assigned to care and/or treat Patient #4 after he/she was brought back into the ED. RN#1 said she thinks Patient #4 was laying on the bed for a couple of hours in the ED treatment area without being re-assessed or seen by a nurse or provider. RN#1 said that while in the ED, Patient #4 fell and staff members in the ED responded to Patient #4, who ultimately coded and needed to be resuscitated and sent out to a higher level of care. RN#1 said after the event there was a debrief and it was discussed that whoever brings patients to the ED treatment area should tell the nurse they are there, which was the same policy as before the event.

During an interview on 9/28/23 at 11:07 A.M., RN#3 said she was working in the ED in the trauma bay area and assumed care of Patient #4 when he/she was brought back to the trauma room after being found unresponsive in the ED treatment area. RN #3 said she was unaware of any education or interventions by the Hospital as a result of this event.

The Hospital failed to ensure a Registered Nurse was assigned to Patient #4 after being brought to the ED treatment area from triage. Patient #4 was not reassessed or evaluated by a nurse or provider until roughly 1:30 P.M. on 7/20/23, after he/she was found in the hall of the ED unresponsive with facial cyanosis and bradycardia. Patient #4 was ultimately resuscitated and transferred to a higher level of care. The Hospital failed to produce any evidence of corrective actions implemented or staff re-education to prevent a like occurrence from happening.

3. Patient #3 presented to the ED on 7/31/23, by ambulance for shortness of breath and headache. A chest computerized tomography (CT) scan revealed Patient #3 had bilateral pulmonary emboli and he/she was started on intravenous (IV) Heparin (a high risk anticoagulant medication used to decrease clotting ability of the blood) on 7/31/23, at 4:10 P.M. with instructions to titrate according to Heparin-DVT-PE-Ischemic Limb Xa protocol, which indicated if an Anti-Xa level was 1 International Units/ milliliter (IU/ml) or greater to hold the infusion for 1 hour and then decrease the infusion by 4 units per kilogram per hour.

Review of Patient #3's medical record indicated he/she received IV Heparin continuously at 16.98 milliliters/hour (mls/hr) from 6:02 P.M on 7/31/23, until 7:05 A.M. on 8/1/23, despite an Anti-Xa level of 1.06 IU/ml at 12:48 A.M. on 8/1/23, which indicated that Patient #3's Heparin drip should have been held for one hour and then restarted at a lower rate according to the order. Patient #3's physician note dated 8/1/23 indicated that he/she had no nurse assigned to him/her overnight from 7/31/23 until the day shift on 8/1/23 and during the night Patient #3 started requiring more oxygen. A Physician Note, dated 8/1/21, indicated that on 8/1/23, Patient #3 had a soft blood pressures and using his/her accessory muscles to breathe, and his/her oxygen saturation was 85% and a rapid response was called.

Review of the Hospital Event Report (RL) dated 8/1/23, indicated the census in the ED that night was 181 and staffing that night was 10 nurses at 11:00 P.M. and 10 nurses at 3:00 A.M. and was supposed to be 17 nurses at 11:00 P.M. and 14 nurses at 3:00 A.M., based on the nurse staffing grid and that high acuity, volume, and staffing shortages impacted the care of this Patient and indicated that staff education had been performed. The Hospital failed to produce any evidence that re-education of staff had been completed to prevent a like occurrence.

During an interview on 9/27/23 at 2:48 P.M., the Director of Quality and Risk said there were no interventions implemented in response to this lapse in assignment of patient care.

The Hospital failed to produce any evidence of any corrective actions taken or re-education to prevent a like occurrence.

4. Patient #2 presented to the Hospital Emergency Department (ED) on 9/13/23, left the registration line to report chest pain and shortness of breath to the Triage Nurse; however, Patient #2's medical record failed to indicate any documented assessment or any attempt to obtain vital signs prior to Patient #2 collapsing in the registration line in the ED waiting room.

Review of the Hospital Adverse Outcome/ Root Cause Analysis (RCA) for Patient #2 indicated he/she presented to the Emergency Department (ED) on 9/13/23, at approximately 5:30 P.M. and was waiting in line to be registered. Patient #2 left the registration line and walked over to the Triage Registered Nurse (RN) and reported he/she was having acute chest pain, shortness of breath and appeared distressed. The Triage RN sent Patient #2 back to the registration line to be registered without assessing him/her and as he/she continued to wait in the registration line, Patient #2 collapsed onto the floor and a Code Blue was initiated at 5:50 P.M. Patient #2 was noted to be in V-fib arrest (a condition in which the lower heart chambers contract in a very rapid and uncoordinated manner) and required multiple rounds of defibrillation and life-saving medications. Patient #2 was pronounced deceased at 6:29 P.M. The RCA further indicated staff would be re-educated. The Hospital failed to produce any evidence that staff was re-educated to prevent a like occurrence.

During an interview on 9/27/23 at 12:13 P.M., the Director of Nursing Education said she has not been asked to do any re-education with nurses in response to event 9/13 when Patient #2 told the triage nurse he/she was having acute chest pain, shortness of breath and appeared distressed.

The Hospital failed to implement the corrective actions identified during the RCA to prevent a like occurrence.

The Hospital is out of compliance with the Condition of Participation for Nursing Services.

Findings included:

Based on records reviewed and interviews, the Hospital failed to ensure for two patients (Patients #3 and #4) out of a sample of ten patients that a Registered Nurse (RN) supervised and evaluated the nursing care needs for each Emergency Department (ED) patient including the waiting room, resulting in a finding of Immediate Jeopardy.

Immediate Jeopardy (IJ) was identified on 9/28/23, under 482.23 Nursing Services due to failure of the Hospital to ensure that Patient #4 was assigned to a nurse in the Emergency Department treatment area and was reassessed and monitored for changes in status or condition; failure to ensure that patients in the Emergency Department were assigned to nurses for ongoing monitoring and reassessment; and failure to ensure that ED techs bringing patients back from triage to the ED treatment area notified the charge nurse of the patient location.

The Hospital was notified of the IJ on 9/28/23. The Hospital provided an immediate corrective action plan that identified: all patients will be assigned to a nurse upon entry to the ED by the Charge Nurse/designee; an updated Nursing Supervisor shift report to include a review of the ED tracker; ED nurse and tech re-education regarding patient assignment and notification, and audits to be completed.

On 9/29/23, the action plan was verified by observation, tour, review of documentation and interviews as implemented, and Immediate Jeopardy was removed.

Condition of Participation non-compliance for Nursing Services remain.
Cross Reference:
482.23(b): Staffing and Delivery of Care (392)

Based on records reviewed and interviews, the Hospital failed to ensure licensed nurses providing services to patients adhered to the policies and procedures of the Hospital for one Patient (#2) out of a sample of ten patients.

482.23(b)(6): Supervision of Contract Staff (398)

Based on records reviewed and interviews, the Hospital failed to ensure that 2 Patients (#3 and #4), out of a sample of ten patients, needs were met by ongoing assessments and failed to provide nursing staff to meet those needs.

Findings included:

Review of the Hospital policy titled "Emergency Department (ED) Nursing Triage", revised 6/14/22, indicated all patients will receive a rapid triage assessment including chief complaint, allergies, vital signs, and other information, if appropriate, which may include oxygen saturation, last menstrual period, past medical history and weight.

Patients are triaged into one of the five Emergency Severity Index (ESI) levels and Triage Algorithm:

-Level 1: Patients who require immediate evaluation and treatment with the use of many resources.

-Level 2: Patients who require evaluation and treatment as soon as possible with reassessment as needed requiring multiple resources.

-If a patient has been assessed as ESI level 1 or 2, the patient is brought to the ED treatment area expeditiously and an ED attending is notified.

Review of the Hospital policy titled "Patient Assessment, Reassessment and Documentation of Care in the Emergency Department", revised 6/14/22, indicated vital signs are repeated when abnormal, clinically indicated, and prior to admission, or transfer. The minimum frequency of vital signs for active ED patients is every 4 hours and for ED boarder patients is every shift. The Licensed Independent Practitioner (LIP) should be notified of any abnormal vital signs.

1. Patient #4 presented to the ED on 7/20/23, with complaints of shortness of breath and tachycardia (elevated heart rate). Patient #4 was triaged by the Triage Nurse at 9:14 A.M. and his/her heart rate was elevated at 131 (normal range is 60-100 beats per minute). Patient #4 was assigned as an ESI level 2 status and brought back from triage to the ED treatment area. At approximately 1:30 P.M. (more than 4 hours later), Patient #4 was found in the hall with facial cyanosis (a bluish discoloration of skin resulting from inadequate oxygenation of blood) and bradycardic (low heart rate). Patient #4 was unresponsive and assisted with breathing via Bag-valve-mask (a hand-held device used to provide positive pressure ventilation to patients who are not breathing or are not breathing adequately). Patient #4 was brought into an ED room and at approximately 1:47 P.M., Patient #4 lost his/her pulse and cardiopulmonary resuscitation (CPR) was initiated.

During an interview on 9/28/23, at 10:43 A.M., Registered Nurse (RN) #1 said the Triage Nurse called her with concerns about Patient #4 on 7/20/23, and RN#1 said it was okay to send Patient #4 back to a bed in the ED treatment area. RN#1 said Patient #4 was never tracked and her status wasn ' t changed in the ED tracker, so a Registered Nurse was not assigned to care and/or treat Patient #4 after he/she was brought back into the ED. RN#1 said she thinks Patient #4 was laying on the bed for a couple of hours in the ED treatment area without being re-assessed or seen by a nurse or provider. RN#1 said that while in the ED, Patient #4 fell and staff members in the ED responded to Patient #4, who ultimately coded and needed to be resuscitated and sent out to a higher level of care. RN#1 said after the event there was a debrief and it was discussed that whoever brings patients to the ED treatment area should tell the nurse they are there, which was the same policy as before the event.

During an interview on 9/28/23 at 11:07 A.M., RN#3 said she was working in the ED in the trauma bay area and assumed care of Patient #4 when he/she was brought back to the trauma room after being found unresponsive in the ED treatment area.

During an interview on 9/28/23 at 9:55 A.M., the Chairman of Emergency Medicine said his first interaction with Patient #4 was when he was notified by a nurse in the ED treatment area that the Patient didn ' t look good and when he assessed him/her, he brought Patient #4 back to a trauma room because he thought he/she was going to code soon. The Chairman of Emergency Medicine said Patient #4 ultimately coded and was subsequently intubated and CPR was performed. The Chairman of Emergency Medicine said if there was a delay in care, it would have been from the nurse-to-nurse handoff and that in the ED nursing volume and acuity is through the roof and Nurse staffing needs to be improved.

The Hospital failed to ensure a Registered Nurse was assigned to Patient #4 after being brought to a bed in the ED treatment area. Patient #4 was not reassessed or evaluated by a nurse or provider until approximately 1:30 P.M.(4 hours after being triaged on 7/20/23 after he/she was found in the hall of the ED unresponsive with facial cyanosis and bradycardia. Patient #4 was ultimately resuscitated and transferred to a higher level of care.

2) Patient #3 presented to the ED on 7/31/23, by ambulance, for shortness of breath and headache. A chest computerized tomography (CT) scan revealed Patient #3 had bilateral pulmonary emboli and he/she was started on intravenous (IV) Heparin (a high risk anticoagulant medication used to decrease clotting ability of the blood) on 7/31/23, at 4:10 P.M. with instructions to titrate according to Heparin-DVT-PE-Ischemic Limb Xa protocol, which indicated if an Anti-Xa level was 1 International Units/ milliliter (IU/ml) or greater to hold the infusion for 1 hour and then decrease the infusion by 4 units per kilogram per hour.

Review of Patient #3 ' s medical record indicated he/she received IV Heparin continuously at 16.98 milliliters/hour (mls/hr) from 6:02 P.M on 7/31/23 until 7:05 A.M. on 8/1/23, despite an Anti-Xa level of 1.06 IU/ml at 12:48 A.M. on 8/1/23, which indicated that Patient #3 ' s Heparin drip should have been held for one hour and then restarted at a lower rate according to the order. Patient #3 ' s physician note dated 8/1/23 indicated that he/she had no nurse assigned to him/her overnight from 7/31/23 until the day shift on 8/1/23 and during the night Patient #3 started requiring more oxygen. A Physician Note, dated 8/1/21, indicated that on 8/1/23, Patient #3 had a soft blood pressures and using his/her accessory muscles to breathe, and his/her oxygen saturation was 85% and a rapid response was called.

Review of the Hospital event report (RL) dated 8/1/23 indicated the census in the ED that night was 181 and staffing that night was 10 nurses at 11:00 P.M. and 10 nurses at 3:00 A.M. and was supposed to be 17 nurses at 11:00 P.M. and 14 nurses at 3:00 A.M., based on the nurse staffing grid.

During an interview on 9/28/23 at 10:59 A.M. Registered Nurse (RN) #3 said IV Heparin is a high-risk medication and the titration protocol should be followed and lab values monitored for dosing. RN#3 said when she came on day shift on 8/1/23 there was no overnight nurse to get report from regarding Patient #3 on Patient #3 from RN#3 said she assessed the Patient, saw that his/her Heparin drip was running still and reviewed his/her labs which showed an elevated Anti-Xa level, so she stopped the Heparin drip. RN#3 said Patient #3 was having shortness of breath even with supplemental oxygen so she and a midlevel provider called a rapid response. RN#3 said her understanding of the situation of the overnight shift was that the ED nurse gave report off on 5 patients, including Patient #3, around 11:00 P.M. to a float nurse who subsequently left the ED shortly after getting report. The float nurse did not provide any report or handoff on her patients to any other RNs. The nursing supervisor came to the ED and moved some patients that had been assigned to the float nurse to other units, but Patient #3 was not assigned to any RN for the overnight shift. RN#3 said the ball was dropped for Patient #3 and said if a RN is not assigned to a patient, there is no one responsible for his/her care.

During an interview on 9/28/23 at 11:15 A.M., RN #2 said she works as an inpatient float pool nurse and there was a shift when she went to the ED for her assignment, which was supposed to be 5 inpatient boarders in the ED. RN #2 said while getting report she realized it was going to be for 15 patients: 5 inpatient ED boarders and 10 other patients who she was only assigned to watch. RN#2 said that of the 5 inpatient ED boarders one was receiving IV weight-based Heparin drip with labs due at midnight. RN#2 said she felt unsafe with this assignment so she notified the nursing supervisor of her concerns and left the unit. RN#2 said her understanding was that the nursing supervisor moved 3 of the patients up to inpatient units but she was unaware of any other patients' disposition.

During an interview on 9/27/23 at 2:48 P. M., the Director of Quality and Risk said there were no interventions implemented in response to this lapse in assignment of patient care.

During an interview on 10/4/23 at 1:07 P.M. the ED Director said that she was unsure if a Code Help (a hospital wide response and mobilization of resources to improve patient flow through the ED) had been initiated to help with the high ED census and low nurse staffing 7/31-8/1. She said staff called her separately to come in after the float nurse left the ED after taking report. The ED Director said that there were approximately 10 patients that had no nurse assigned to them and that she and the nursing supervisor performed team nursing to administer medications, but that no nurse was directly assigned nor responsible for the 10 patients care or for the patients' ongoing monitoring and assessments.

The Hospital failed to ensure Patient #3 was monitored and had a Registered Nurse assigned for his/her care while receiving a high-risk IV medication and subsequently required a rapid response after nursing staff failed to adjust his/her IV infusion as ordered.

Based on records reviewed and interviews, the Hospital failed to ensure a Registered Nurse (RN) performed a brief, rapid assessment for one Patient (#2) in the Emergency Department (ED) out of ten sampled patients.

Findings included:

Review of Hospital Policy titled: Patient Assessment, Reassessment and Documentation of Care in the Emergency Department, revised 6/14/22, indicated that upon initial contact with a Registered Nurse, a brief, rapid assessment is completed.

Review of Emergency Department (ED) Nursing Triage Policy, revised 6/14/22, indicated that all patients will receive a rapid triage assessment including chief complaint, allergies, vital signs, and other information, if appropriate, which may include oxygen saturation, last menstrual period, past medical history, and weight.

Patients are triaged into one of the five Emergency Severity Index (ESI) levels and Triage Algorithm:

-Level 1: Patients who require immediate evaluation and treatment with the use of many resources.

-Level 2: Patients who require evaluation and treatment as soon as possible with reassessment as needed requiring multiple resources.

-Level 3: Stable patients who could wait for evaluation and treatment requiring multiple diagnostic and therapeutic resources.

-Level 4: Stable patients who could wait for evaluation and treatment requiring one therapeutic diagnostic resource.

-Level 5: Stable patients who could wait for evaluation and treatment and require minimal or no resources

Review of Patient #2's record indicated on 9/13/23 he/she presented to the Hospital Emergency Room (ER) and reported chest pain and shortness of breath to the Triage Nurse. The Triage Nurse sent Patient #2 back to the waiting room to get registered and shortly afterwards he/she fell forward and collapsed on the floor. Patient #2 was noted to be cyanotic (bluish discoloration of skin resulting from inadequate oxygenation of blood) and he/she was immediately brought back into the ER where he/she was noted to be pulseless, and a code for resuscitation was initiated. Further review of Patient #2's medical record failed to indicate any assessment or any attempt to obtain vital signs were performed prior to Patient #2 collapsing in the ER waiting room.

Review of the Hospital Adverse Outcome/ Root Cause Analysis for Patient #2 indicated the Patient presented to the Emergency Department (ED) on 9/13/23 at approximately 5:30 P.M. and was waiting in line to be registered. Patient #2 left the registration line and walked over to the Triage Registered Nurse (RN) and reported he/she was having acute chest pain, shortness of breath and appeared distressed. The Triage RN sent Patient #2 back to the registration line to be registered without assessing him/her and as he/she continued to wait in the registration line, Patient #2 collapsed onto the floor and a Code Blue was initiated at 5:50 P.M. Patient #2 was noted to be in V-fib arrest (a condition in which the lower heart chambers contract in a very rapid and uncoordinated manner) and required multiple rounds of defibrillation and life-saving medications. Patient #2 was pronounced deceased at 6:29 P.M.

During an interview on 10/4/23 at 1:07 P.M., the ED Director said that when Patient #2 went into the triage office, saw the Triage Nurse and reported acute chest pain and shortness of breath, the Triage Nurse should have completed a rapid assessment on the Patient in accordance with protocol. The ED Director said the Triage Nurse should have followed protocol, obtained vital signs on Patient #2, and done a preliminary assessment. The ED Director said that the Triage Nurse said she felt strongly that Patient #2 had anxiety and talked to him/her for about 2 minutes and said that "we talked him/her down" and had him/her go back out to get registered.

The Hospital failed to ensure a Registered Nurse assessed or evaluated Patient #2 who reported acute chest pain, shortness of breath, and appeared to be in distress; Patient #2 collapsed while waiting to be registered in the waiting room of the Hospital ER and died despite resuscitation efforts.

The Condition of Participation: Emergency Services was out of compliance.

Findings included:

Based on records reviewed and interviews, the Hospital Emergency (ED) Services failed to ensure patients seeking medical care were identified and appropriately tracked and reassessed in the ED/waiting room; failed to ensure staff called a "Code Help" when staff were unable to care for patients in the ED/waiting room impeding the provision of safe patient care; and failed to complete and review Code Help documentation, in accordance with the Hospital Policy.

An Immediate Jeopardy (IJ) event was identified for the Conditions of Participation (CoP) of Emergency Services (42 CFR 482.55) for failure to ensure the Hospital met the emergency needs of patients in accordance with acceptable standards of practice.

The Hospital provided an immediate corrective action plan that identified the following: Patients arriving by emergency medical services will not be triaged to the ED waiting room; ED Tech assigned to the ED waiting room to complete and document patient assessments, rounding, and communicate patient needs with the Triage Nurse(s); ED Tech education on the new ED waiting room assignment and responsibilities; Triage Nurse re-education on patient assessment, reassessment, and documentation of care in the Emergency Department; The Plan results of all audits in this section will be reported weekly to Senior Leadership, and monthly to the Emergency Departmental meeting, Quality and Safety Committee and Patient Care Assessment Committee.

On 9/27/23, the action plan was verified by observation, tour, review of documentation and interviews as implemented, and Immediate Jeopardy was removed.

CoP non-compliance for Emergency Services remains.

Cross Reference:
482.55(a)(2): Emergency Services: Integration of Emergency Services (1103)
482.55(a)(3): Emergency Services: Emergency Services Policies (1104)

Based on records reviewed and interviews the Hospital Emergency (ED) Services failed to ensure patients seeking medical care were identified and appropriately tracked and reassessed in the ED waiting room; failed to ensure staff called a "Code Help" when staff were unable to care for patients in the ED/waiting room impeding the provision of safe patient care; and failed to complete and review Code Help documentation, in accordance with the Hospital Policy.

Findings included:

The Hospital's Policy titled Code Help, dated 5/24/22, indicated a "Code Help" would be initiated when the ED was unable to accept any new patients or was unable to care for existing patients because the acuity impeded the provision of safe patient care. The Policy defined Code Help as a hospital-wide response and mobilization of resources to improve patient flow through the ED, enhancing safety, quality, and the patient experience. The Policy indicated that after a Code Help was completed, the ED MD/Manager/Designee would complete the appropriate documentation and would submit to the Environment of Care (EOC) Committee for presentation at the next meeting and develop lessons learned and an applicable corrective action plan to the Quality and Safety Committee for monthly review. The Policy indicated the EOC Committee Chair would pull a list of Code Help's each month to ensure there was a complete review and improvement plan for every Code Help initiation.

1. Review of the Hospital's Incident Report indicated that on 9/11/2023, at 9:37 A.M., Patient #1 presented to the Hospital ' s ED via emergency medical services with complaints of nausea, vomiting and right flank pain. Around 9:49 A.M. the Triage Nurse assessed Patient #1 as an ESI level three. Patient #1 was orally administered four milligrams (mg) of Zofran (anti-nausea medication) and diagnostic labs were ordered. Patient #1 was placed back in the ED waiting room until an ED bed became available for a full medical evaluation.

The Hospital's Incident Report indicated that around 6:19 P.M., a Triage Nurse reported attempting to call out to Patient #1 for an evaluation followed be calling Patient #1's cell phone, both without a response. At 7:40 P.M., the Triage Nurse assumed that Patient #1 eloped from the ED waiting room and his/her disposition status in the medical record was documented as eloped.

The Hospital's Incident Report indicated that around 8:30 P.M., Patient #1's friend presented to the ED and noticed Patient #1 was seated in the ED waiting room and was weak and minimally responsive. Patient #1's friend alerted the Triage Nurse and Patient #1 was immediately brought into the ED and was intubated and admitted to the intensive care unit.

The Hospital's Adverse Outcome/Root Cause Analysis (RCA)'s meeting minutes, dated 9/21/23, indicated that during a meeting with Risk Management, the Triage Nurse said she did not re-assess Patient #1 in the ED waiting room because she was extremely busy and was behind, trying to catch up on [ED] patients.

During an interview on 9/26/23 at 1:56 P.M., the Senior Director of Quality and Behavioral Health Services said she was unsure if the Triage Nurse had notified nursing leadership on 9/11/23, when she was busy and unable to reassess Patient #1 in the ED waiting room. The Director said there was no documentation to support the hospital developed, implemented, or monitored re-education on calling a Code Help and/or reporting the inability to care for existing patients because the acuity impeded the provision of safe patient care.

2. Review of the Hospital's Code Help Activation Summary, Emergency Department, dated 8/7/23, 8/21/23, and 8/22/23, indicated there was no documentation to support the Hospital reviewed and/or completed the following tasks listed on the Code Help Activation Summary's section titled Post Code Help Improvement Planning Matrix which included: Process/Activity/task; Improvement Plan; responsible [person]; and date.

Based on records reviewed and interviews, the Hospital's emergency services failed to ensure policies and procedures governing medical care provided in the emergency department were reviewed and/or revised by the responsible medical staff, in accordance with Hospital procedure.

Findings included:

Review of the Hospital's policy titled, Emergency Service Plan Policy, dated April 2017, indicated the objective was to treat each patient as an individual and provide patient care according to the current standards of emergency nursing practice and medical care and provide a framework for a collaborative and systematic approach for the ongoing assessment and monitoring of the quality, appropriateness, and effectiveness of patient care in the ED.

Further review of the Policy indicated the Policy would be reviewed semiannually by the ED Patient Care Director and the ED Chairman. The Policy indicated the next planned revision was scheduled for April 2020.

At the time of the Survey, in September 2023, there was no documentation to support the Hospital reviewed and/or revised the Emergency Service Plan Policy since April 2017, approximately six years ago.

During an interview on 10/4/23 at 11:49 A.M., the Performance Improvement Manager, acknowledged the Hospital last reviewed and/or revised the Emergency Service Plan Policy was in April 2017, which was an incidental finding discovered at the time of the Survey.