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Based on observation, interview, and record review, the hospital failed to ensure the licensed nurses documentation contained information necessary to monitor one of 31 sampled patient's condition (49) receiving a Hemodialysis (a procedure in which impurities or wastes are removed from the blood) treatment. This failure had the potential to result in unmet care needs.

Findings:

During an observation with Registered Nurse (RN) 22, on 2/16/16, at 9:40 AM, in the patient's room, Patient 49 was in bed with the head part slightly elevated at 30 degree angle. He had an oxygen inhalation via nasal cannula. Patient 49 waved his hand when he was asked how he was doing.

During an interview with RN 22, on 2/16/16, at 9:42 AM, she stated Patient 49 was on Hemodialysis three times a week. RN 22 also stated Patient 49 was alert and oriented and he was able to make his needs known.

During a review of the clinical record for Patient 49, the Physician's Order dated 2/16/16, indicated Patient 49 to receive "Hemodialysis STAT ONCE [immediately one time] for 2 hours dry - DX [diagnosis]: Hypoxia [inadequate oxygen tension at the cellular level]." During further review of the clinical record for Patient 49, there was no documentation by the licensed nursing staff for the Hemodialysis treatment ordered on 2/16/16. The Hemodialysis treatment was an additional order by the physician from Patient 49's current order of three times a week (Monday-Wednesday-Friday). It was ordered due to Patient 49's hypoxia.

During an interview with RN 24, on 2/17/16, at 9:15 AM, RN 24 reviewed the licensed nurses documentation and verified there was no information found for the Hemodialysis STAT order. He also stated the licensed staff did not document the reason for the order and Patient 49's response to the treatment.

During an interview with Vice President- Hospital Operations (VP) 2 and RN 24, on 2/17/16, at 9:50 AM, they were made aware of the lack of documentation by the licensed nursing staff for the one time STAT order of Patient 49's Hemodialysis treatment. VP 2 and RN 24 both gave no further information.

The hospital policy and procedure titled "Assessment/Reassessment of Patient" dated 4/16/15, read in part, "...A-3. The goal of the assessment/reassessment process is to provide the patient the best care and treatment possible... 7. All reported changes in patient condition will be documented, as well as the patient response in the medical record..."

Based on observation, interview, and record review, the registered nurses failed to ensure there was adequate supervision when:

1. One of 31 sampled patients (27) was waiting in the hallway on an ambulance gurney for a bed in the Urgent Care for 4 hours with no nursing re-evaluation or check during his wait. This had the potential to result in medical conditions to go untreated.

2. Five call lights were observed not functioning (Room 111C, 111D, 111F, 111G, 105A) as intended and three call lights were not accessible for the patients to use in Room 111B, 110B, and 110C. This had the potential for the patients to be unable to call for required assistance.

3. The physician's orders were not followed for two of 31 sampled patients (38 and 45). This had the potential to result in untreated medical conditions which could result in an overall decline in the patients.

4. Nursing was unaware of the hospital's policy for the crash cart and one crash cart did not contain all the contents listed. This had the potential to result in the emergency personnel to be unaware of the contents and to ensure the crash cart contained all the emergency contents.

Findings:

1. During an observation and interview on 2/16/16, at 9 AM, Patient 27 was noted to be lying on an EMT (emergency medical technician) gurney in the hallway directly outside Urgent Care. An ambulance attendant (EMT 1) was sitting next to him. EMT 1 stated he brought Patient 27 to the hospital about 5 AM. and they have been waiting for a bed in the Urgent Care. EMT 1 stated no nurse has re-evaluated Patient 27 or taken the vital signs (blood pressure, pulse, temperature) since their arrival.

During an observation and record review on 2/16/2016, at 9:40 AM, the Chief Nursing Officer (CNO) assisted EMT 1 to bring Patient 27 into the Urgent Care. Patient 27's medical record was reviewed and it documented that vital signs had been taken at 5:45 AM and not repeated until 9:30 AM. The registered nurse in charge of the Urgent Care (RN 6) stated patients who were waiting for a bed in the Urgent Care should have their vital signs taken every two hours.

The hospital policy and procedure titled "Triage Treatment Protocols and Admission in the Emergency Department", dated 3/2014, indicated: "....2.12 It is the responsibility of the RN to continually reassess the status of those patients who are awaiting disposition to the treatment area ...."



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2a. During an observation and interview with the RN 25 (the charge nurse for the medical surgical unit) and the Certified Nursing Assistant (CNA) 1 on 2/16/16, at 11:46 AM, Room 111 was noted with eight patients. Patient 39 (Room 111) was observed lying in bed G with CNA 1 next to his bed. The patient appeared confused and the call light button was not observed within reach of Patient 39. CNA 1 indicated she removed the call light from the patient because "he is always on it" but he did have it earlier. CNA 1 and RN 25 proceeded to search for the call light. When the call light button was found, the cord was cut at the level of the wall; therefore, could not be accessible for Patient 39 to use. Patient 39 was approximately 2 feet from the call light. RN 25 stated CNA 1 is the assigned staff to care for Patient 39. She was asked how the nurse call system works. She stated the nurse call system includes a button at the wall with a cord that has the call light attached to it. The cord with the call light attached is what is provided to the patient. When the patient presses the red call light, it should be audible and visible above the patient room door and at the nurse's station.

During a review of the clinical record for Patient 39 and interview with RN 22, on 2/16/16, at 2 PM, the admitting diagnoses included: Altered Mental Status (AMS), Hypertension (high blood pressure), Diabetes Mellitus (a disease which results in the body's inability to produce enough insulin which results in elevated sugar levels), Abnormal Gait, Dementia and Convulsions. The care plan problem list included a care plan for patient's risk for harming himself, a care plan for pain and a care plan of fall. The fall care plan included an intervention which indicated, "...call bell within reach..."

2b. During an observation of Room 111 Bed B with RN 25, on 2/16/16, at 11:50 AM, the call light was not noted accessible to Patient 42 who was lying in bed. RN 25 proceeded to search for the call light, which was found on the floor.

During a review of the clinical record for Patient 42 with RN 22 and the Assistant Chief Nursing Officer (ACNO), on 2/16/16, at 2:50 PM, the patient was admitted on 2/11/16 with admitting diagnoses of Gastrointestinal (relating to the stomach or intestines) Bleed, Gastric Cancer and Anemia (a condition where you do not have enough healthy red blood cells to carry adequate oxygen to the body's tissue which can can cause weakness, fatigue and dizziness). Additional diagnoses included Failure to Thrive (FTT used to define faultering weight to indicate insufficient weight gain), nausea and vomiting, Schizophrenia (mental disorder), Diabetes, Gastritis (inflammation of the lining of the stomach), and Gastroesophageal Reflux Disease (a chronic digestive disorder which results in the stomach acid to flow back up through the food pipe [esophagus]). The care plan list was reviewed and there was a care plan which addressed his fall risk with an intervention to assist the patient from falling included "...call bell within reach..." A care plan was also developed due to the patient being harmful to himself due to the patient being impulsive and wandering tendencies and an intervention to assist the patient from harming himself is to "ensure safe environment".

2c. During an observation of Room 111 Bed C with RN 25, on 2/16/16, at 11:50 AM, Patient 43 was observed lying in bed. The call light was non functioning with no audible sound above the room door or at the nurse's station.

During a review of the clinical record for Patient 43 with RN 22 and the ACNO, on 2/16/16, at 3:20 PM, the patient was admitted on 2/14/16 with diagnoses of Mysitis (inflammation and degeneration of the muscle tissue), difficulty walking, and diabetes. A care plan problem was noted for fall risk with an intervention which included "call bell within reach".

2d. During an observation of Room 105 Bed A with RN 25, on 2/16/16, at 12 PM, Patient 41 was observed sitting at the edge of the bed with a lunch tray on the bedside table. When the call light was pressed to determine if it was functioning as intended, the call light was not audible or visible above the room door or at the nurse's station. Patient 41 stated, she thought the call light was broken when she called last night and no one came.

During an interview with Patient 41, on 2/16/16, at 1:38 PM, she stated she used the call light last night to get assistance to the bathroom. Patient 41 was asked how long she waited, but she was unsure. When no one came to her room, she walked to the door to ask for assistance. She said she used the call light again today to ask for a brief, but RN 22 entered the room as she was using her call light.

During a review of the clinical record for Patient 41 with RN 22 and the ACNO, on 2/16/16, at 2:40 PM, the patient was admitted on 2/14/16 for complaints of abdominal pain. The care plan problem list was reviewed and it included a fall care plan. The interventions included "...call bell within reach..."

2e. During an observation of Patient 40 with RN 25, on 2/16/16, at 11:55 AM, in Room 110 Bed C, the patient was observed lying in bed. A call light to contact the nurse was not noted within reach of the patient. The patient was asked if she had a call light that could be used to call the nurse. As she felt around her bed, she was unable to locate a call light. She stated she was unable to see due to being "Legally Blind and (having) Macular Degeneration (an eye disease that progressively causes severe vision loss)". RN 25 proceeded to feel around the bed for the call light, which was then given to the patient. After be

Based on interview and record review, the hospital failed to provide documented evidence one Registered Nurse (RN 16) was oriented to the emergency department (ED) when she was transferred there from another department. This had the potential to result in RN 16 being unprepared to perform her duties in the ED effectively affecting patient care.

Findings:

During an interview with RN 16, on 2/16/16, at 8:53 AM, she stated she has been an RN at the hospital for approximately two years.

During a review of RN 16's personnel file and interview with Human Resource Coordinator, on 2/17/16, at 11:12 AM, it was noted RN 16 transferred to the ED on 11/1/15. There was no documentation RN 16 was oriented to the ED. No further evidence was provided.