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Tag No.: C0200
Based on staff interview and review of medical records and policies, it was determined the CAH failed to ensure emergency care was provided sufficient to meet the needs of 8 of 23 patients (#4, #7, #15, #16, #18, #19, #22, and #23) who presented to the ER seeking care and whose records were reviewed. This resulted in the inability of the CAH to triage patients and to ensure they were monitored while waiting for examination by a physician. Findings include:
1. The hospital had not provided specific direction to staff for triaging patients in the ED and monitoring them while they waited to be examined by a physician. This led to a lack of care provided to patients.
a. The policy "Emergency Department Triage Policy," dated January, 2009, defined triage as "The sorting out and classification of patients or casualties to determine priority of need and proper place of treatment." The policy stated "Each Emergency Department will determine: 1.2 Who initially assesses the patient. 1.2.1 Where this initial assessment takes place. 1.2.2 Training required of those performing the initial assessment. 1.3 Components of the initial assessment to be performed based upon the patient's chief complaint and/or reason for coming to the ED. 1.3.1 Training required of the staff performing the assessment. 1.4 The minimum criteria that comprises the initial nursing triage/assessment of the patient. 1.4.1 Components of the nursing triage/assessment to be performed based upon the patient's chief complaint and/or reason for coming to the ED. 1.4.2 Training required of the staff performing the assessment." The policy stated the ED would use a 5 level triage classification system including resuscitative, emergent, urgent, semi-urgent, and non-urgent. The policy did not specifically state who could perform a triage assessment or the training required to do so. The policy did not specifically define a minimum triage assessment, for example, whether vital signs were required or not. The policy did not define where the triage assessment should take place. In addition, the policy did not specify how patients would be monitored after they were triaged and while they were waiting to be examined by a physician.
The Director of Quality and Risk Management was interviewed 4/18/12 beginning at 11:05 AM. She stated the hospital did not have specific policies defining the triage process and the monitoring of patients. She stated the hospital had developed specific policies in the past but these policies had been rescinded and replaced by the current policy. She also confirmed a policy regarding the monitoring of patients while waiting for examination had not been developed.
b. Patient #15 was a 16 year old male who came to the ED on 3/31/12. The time of registration entered into Patient #15's record was 5:39 PM. The triage RN assigned Patient #15 acuity of "Urgent" at 5:32 PM, and noted "shot with BB hit inside L (left) eye/nose (with) pain." The "PRIMARY ASSESSMENT" by the RN was timed at 6:43 PM, which was 1 hour, 10 minutes after the triage. It was not clear how the classification of "Urgent" was determined, or why the care for Patient #15 was delayed for more than 1 hour.
The ED Manager was interviewed 4/18/12 beginning at 11:30 AM. She reviewed Patient #15's record and confirmed the times of triage as well as, the primary assessment. She was unable to determine why the primary assessment was delayed with acuity of "Urgent."
c. Patient #19 was a 36 year old female who came to the ED on 3/29/12. The time of registration entered into Patient #19's record was 7:17 PM. The triage RN assigned Patient #19 acuity of "Semi-Urgent" at 7:10 PM, and noted "(patient) feels shaky ~5 hrs. Hx (history) DM, BG (blood glucose) 218 today." The "PRIMARY ASSESSMENT" by the RN was timed at 7:40 PM, which was 30 minutes after the triage. It was not clear how the classification of "Semi-Urgent" was determined, or why the care for Patient #19 was delayed 30 minutes.
The ED Manager was interviewed 4/18/12 beginning at 11:45 AM. She reviewed Patient #19's record and confirmed the triage and primary assessment times. The ED Manager stated the practice of the RN was to evaluate each patient individually, and assign triage acuity. She was unable to state specific criteria for triage acuity and related activities.
d. Patient #7's medical record documented a 31 year old female who presented to the ED on 4/12/12 at 8:53 AM. The EDR stated Patient #7's chief complaint was "migraine." The triage section of the EDR stated "Pt was seen in [physician office] & given Amlodipine [a blood pressure medication] & has been nauseated." The triage section of the EDR also stated her blood pressure was elevated. The "Triage Acuity" section stated Patient #7 was classified as "Semi-urgent." It was not clear how this classification was determined since no assessment or vital signs were documented.
Patient #7's EDR contained a section labeled "PRIMARY ASSESSMENT" which documented an assessment by the RN beginning at 10:10 AM. It stated Patient #7 had vomited and her pain level was 7-8 of 10. A check indicated a neurological assessment was within defined limits, or normal. Her blood pressure was 158/126. (Medline Plus, a service of the National Institutes for Health, defined normal blood pressure as 120/80 or lower. It defined high blood pressure as 140/90 or above.)
The EDR documented the physician examined Patient #7 beginning at 10:30 AM on 4/12/12. The "ED Physician/LIP Report," dated 4/12/12 at 12:36 PM, diagnosed Patient #7 with headache and "Hypertension, which could be related to each other." Patient #7 was treated with IV fluids, IV narcotic pain medication, and IV anti-nausea medication.
Patient #7 was discharged home at 12:48 PM. Nursing notes stated her pain level had decreased to 2/10. Her blood pressure continued to be very high, however. The last documented blood pressure was dated 4/12/12 at 12:51 PM. It was 172/128.
The RN who cared for Patient #7 was interviewed on 4/18/12 beginning at 8:05 AM. She reviewed the EDR. She stated Patient #7 had presented to the ED at 8:53 on 4/12/12. She stated she had come to the window in the reception area and talked with Patient #7. She stated Patient #7 complained of a headache and said her blood pressure was high. The RN stated Patient #7 had an appointment with her primary care physician off site at 9:15 AM but her headache was very painful so she came to the ED for treatment. The RN stated the ED was busy so Patient #7 was told it would be faster if she left and went to the appointment with her primary care physician. The RN stated Patient #7 left the ED and went to her physician appointment and returned later that morning. The RN confirmed this was not documented.
The RN who cared for Patient #7 was asked about the triage level assigned to Patient #7. She stated she did not assess Patient #7 except to speak with her briefly. She stated she did not take Patient #7's vital signs. No physical assessment was done prior to Patient #7 leaving the ED. The RN stated she completed some triage assessments without physically examining patient and without taking their vital signs. She stated patients were assigned a triage acuity level based only on a short conversation. She stated she was not aware of a hospital policy that defined triage assessments or listed a procedure for them.
e. Patient #22's medical record documented a 30 year old female who presented to the ED on 3/15/12 complaining of left ear pain. The time of her arrival was not documented. A set of vital signs was documented at 10:32 PM on 3/15/12. These were within normal limits. Except for the vital signs, no contact with an RN was documented. No triage assessment was documented. No triage acuity level was assigned. No examination by a physician was documented. A form, "REJECTION OF TREATMENT/LEAVING AGAINST MEDICAL ADVICE," dated 3/15/12, was signed by Patient #22 and an RN. The time it was signed was not documented. An "ED Nurse Visit Note," dated 3/16/12 at 1:00 AM, stated Patient #22 left without treatment because the wait was too long. No other documentation was present to explain the course of events for Patient #22.
The medical record for Patient #22 was reviewed with the ED Manager on 4/18/12 beginning at 11:40 AM. She confirmed a triage assessment was not documented. She stated she could not tell when Patient #22 presented to the ED. Since Patient #22 was at the ED at least 2 hours and 28 minutes without documentation of an assessment, the ED Manager was asked about a policy for monitoring patients while they waited to be examined. She stated staff tried to check the waiting room every 15 to 30 minutes. She stated staff did not document this. She also stated a policy specifying how patients would be monitored had not been developed.
f. Patient #23's medical record documented a 58 year old male who presented to the ED on 3/15/12 at 11:18 PM complaining of leg pain. No documentation was present to show Patient #23 was triaged or otherwise assessed by an RN. No examination by a physician was documented. A form, "REJECTION OF TREATMENT/LEAVING AGAINST MEDICAL ADVICE," dated 3/15/12, was signed by Patient #23 and an RN. The time it was signed was not documented. The form stated Patient #23 decided not to wait and went to another emergency room.
An "ED Nurse Visit Note," dated 3/16/12 at 1:02 AM, stated Patient #23 left without treatment because the wait was too long.
The medical record for Patient #23 was reviewed with the ED Manager on 4/18/12 beginning at 11:40 AM. She confirmed a triage assessment was not documented. She confirmed no documentation was present that Patient #23 was monitored during the 1 hour and 44 minutes while he waited to be seen.
g. Patient #16 was a 6 year old female who came to the ED on 3/29/12. The time of registration entered into Patient #19's record was 5:30 PM. The triage RN documented Patient #16 had complained of left wrist pain after falling off of a trampoline. Triage acuity for Patient #16 was not documented, and there was no triage time, although the arrival time on the EDR stated 3:30 PM and 6:20 PM.
The "PRIMARY ASSESSMENT" by the RN was timed at 6:20 PM, and included a note as follows: "1600 (4:00 PM) - pt arrived @ 1500 (3:00 PM,) LWOT @ 1600- back at 1820 (6:20 PM) to be seen."
It was unclear if Patient #16 had been initially triaged at 4:00 PM, or at 6:20 PM. The EDR did not contain further documentation of why Patient #16 left, or if there was an assessment of the patient condition before she left. The LWOT form was not in the patient record as the RN had documented in her note.
h. Patient # 4 was a 31 year old male who came to the ED on 12/17/11. The time of registration entered into Patient #4's record was 11:27 AM. The RN documented triage at 11:25 AM, and stated Patient #4 had a past medical history of depression and had taken 15-25 pills of Paxil, an antidepressant. There was no triage acuity assigned.
The "PRIMARY ASSESSMENT" by the RN was timed at 12:17 AM. The EDR contained documentation Patient #4 was placed on a monitor at 12:00 PM. The EDR did not indicate why the assessment and monitoring of Patient #4 had been delayed more than 30 minutes.
In an interview on 4/17/12 at 5:07 PM, the ED Manager reviewed Patient #4's medical record and was unable to determine why assessment and treatment of Patient #4 had been delayed.
The hospital had not developed and implemented a system to triage and monitor ED patients.
2. Diabetic patients were not monitored sufficiently to determine if therapeutic interventions were effective, and ensure documentation of physician notification. Examples are as follows:
a. Patient #18 was a 46 year old male who was an insulin dependent diabetic. He came to the ED on 3/27/12 at 7:55 AM, and the triage note included: "pt. seen in ER on 3/23/12. Scrotum now black and swollen."
The EDR for Patient #18 documented the following events:
-8:10 AM vital signs were obtained.
-8:38 AM blood was drawn for lab work
-9:17 AM report of critical glucose level of 786 called to ED RN, (according to the American Diabetes Association, a diabetic with a blood sugar above 120 would be considered out of normal range.)
-11:00 AM, Regular Insulin 10 units was ordered by the physician,
-11:10 AM, Insulin was administered by the RN,
-12:40 PM, blood sugar tested at bedside, result >600, too high for the bedside glucometer to determine level,
-1:55 PM, Patient was transferred by helicopter to referral facility.
The EDR did not contain documentation of any further blood sugar testing or of confirmation with the lab after determining the glucometer was unable to provide an accurate value.
During an interview with the Director of Quality and Risk Management on 4/18/12 at 2:30 PM. She reviewed Patient #18's record and confirmed the lab and glucometer results. The Director of Quality and Risk Management stated there was no protocol for glucose testing, and would follow physician orders for the testing, whether by glucometer or actual lab draws.
b. Patient #19 was a 36 year old female who came to the ED on 3/29/12. The time of registration entered into Patient #19's record was 7:17 PM. The triage RN assigned Patient #19 acuity level of "Semi-Urgent" at 7:10 PM, and noted "feels shaky ~5 hrs. Hx (history) DM BG (blood glucose) 218 today."
The EDR for Patient #19 documented the following events:
-7:34 vital signs were taken and she was offered orange juice and sugar.
-7:40 PM The "PRIMARY ASSESSMENT" was done by the RN.
-7:48 PM the RN noted a one-touch (glucometer) reading of 68, which was 14 minutes after the orange juice and sugar was offered.
-8:27 PM, the RN documented Patient #19 felt much better, and wanted to go home. Patient #19 signed a LWOT form and left the ED.
The record did not contain documentation that the RN tested Patient #19's blood glucose before offering orange juice and sugar. The RN did not document she had received physician orders for Patient #19 for the glucometer testing or treatment of orange juice and sugar. The record did not contain documentation that the RN had provided patient discharge instructions regarding hypo/hyperglycemia.
In an interview on 4/18/12 at 11:45 AM, the ED Manager reviewed Patient #19's record and confirmed the patient left before being seen by the physician. The ED Manager stated the RN should have obtained a physician order before providing orange juice and sugar to the patient. The ED Manager stated there was not a protocol or policy for ED management of diabetic patients.
The CAH did not ensure comprehensive monitoring of diabetic patients in the ED.
The cumulative effect of these negative facility practices impeded the ability of the facility to provide emergency services in a timely fashion and had the potential to result in negative patient outcomes.
Tag No.: C0274
Based on review of clinical records and hospital policies and staff interview, it was determined the CAH failed to develop and implement policies and procedures governing emergency services. This resulted in a lack of guidance to 1 of 1 staff RN who was interviewed. The lack of direction prevented staff from following a consistent process for the evaluation and monitoring of ED patients. The findings include:
1. The policy "Emergency Department Triage Policy," dated January, 2009, defined triage as "The sorting out and classification of patients or casualties to determine priority of need and proper place of treatment." The policy stated "Each Emergency Department will determine: 1.2 Who initially assesses the patient. 1.2.1 Where this initial assessment takes place. 1.2.2 Training required of those performing the initial assessment. 1.3 Components of the initial assessment to be performed based upon the patient's chief complaint and/or reason for coming to the ED. 1.3.1 Training required of the staff performing the assessment. 1.4 The minimum criteria that comprises the initial nursing triage/assessment of the patient. 1.4.1 Components of the nursing triage/assessment to be performed based upon the patient's chief complaint and/or reason for coming to the ED. 1.4.2 Training required of the staff performing the assessment." The policy stated the ED would use a 5 level triage classification system including resuscitative, emergent, urgent, semi-urgent, and non-urgent. The policy did not specifically state who could perform a triage assessment or the training required to do so. The policy did not specifically define a minimum triage assessment, for example, whether vital signs were required or not. The policy did not define where the triage assessment should take place. In addition, the policy did not specify how patients would be monitored after they were triaged and while they were waiting to be examined by a physician.
The Director of Quality and Risk Management was interviewed 4/18/12 beginning at 11:05 AM. She stated the hospital did not have specific policies defining the triage process and the monitoring of patients. She stated the hospital had developed specific policies in the past but these policies had been rescinded and replaced by the current policy. She also confirmed a policy regarding the monitoring of patients while waiting for examination had not been developed.
2. The RN on duty in the ED was interviewed on 4/18/12 beginning at 8:05 AM. She stated she was not aware of policy which defined the hospital's triage process or how patients were to be monitored while they waited to be examined by a physician. She stated she sometimes talked to patients through the window of the reception area and then assigned those patients a triage acuity level. She stated she did not necessarily perform a physical assessment of patients or take their vital signs in order to assign a triage acuity level. She stated she checked on patients in the waiting area who had not been examined by a physician. However, she stated she did not document this monitoring.
The hospital did not provide direction to staff regarding the nursing assessment and monitoring of ED patients.
Tag No.: C0302
Based on staff interview and review of medical records and policies, the CAH failed to ensure documentation was complete and/or accurate for 6 of 23 ED patients (#4, #7, #16, #8, #22, and #23) whose records were reviewed. This resulted in incomplete or inaccurate medical records. It had the potential to interfere with clarity of information, coordination of care, and accuracy of medication administration. Findings include:
Charting was incomplete in the following patient records:
POLICY
1. Patient #4 was a 31 year old male who presented to the ED on 12/17/12. The Registration form indicated Patient #4 was admitted at 11:27 AM. His triage note was timed 11:25 AM, and stated he took approximately 15-25 pills of Paxil. an antidepressant at 11:00 AM.
A form, titled "Emergency Department Orders," dated 12/17/12, contained preprinted laboratory orders, medication orders, treatments, and radiology tests. The form included a column beside the orders for a physician to write the time of the specific order. Patient #4 had labs drawn, as well as an ECG, as indicated by circles around the specific orders, although the time of those orders was not filled in. Medications, however, were noted to have times in the appropriate columns.
In an interview on 4/17/12 at 5:07 PM the ED Manager reviewed Patient #4's record and confirmed the "Emergency Department Orders" sheet was not timed when the specific orders were written. In addition the ED Manager stated there was no notation of orders by the RN noting receipt of the orders.
The lack of timing of physician's orders lacked clarity of the provision of patient care.
2. Patient #16 was a 6 year old female who came to the ED on 3/29/12. The time of registration entered into Patient #19's record was 5:30 PM. The triage RN documented Patient #16 had complained of left wrist pain after falling off of a trampoline. Triage acuity for Patient #16 was not documented, and there was no triage time, although the arrival time on the EDR stated 3:30 PM and 6:20 PM.
The "PRIMARY ASSESSMENT" by the RN was timed at 6:20 PM, and included a note as follows: "1600 (4:00 PM) - pt arrived @ 1500 (3:00 PM,) LWOT @ 1600- back at 1820 (6:20 PM) to be seen."
It was unclear if Patient #16 had been initially triaged at 4:00 PM, or at 6:20 PM. The EDR did not contain further documentation of why Patient #16 left, or if there was an assessment of the patient condition before she left. The LWOT form was not in the patient record as the RN had documented in her note.
In an interview on 4/17/12 at 4:30 PM, the Director of Quality and Risk Management reviewed Patient #16's record and confirmed a LWOT form had not been signed, the record did not indicate why the patient had left then returned, and the ARN did not triage the patient.
3. Patient #18 was a 46 year old male who was an insulin dependent diabetic. He came to the ED on 3/27/12 at 7:55 AM, and the triage note included: "pt. seen in ER on 3/23/12. Scrotum now black and swollen." A form, titled "EMERGENCY DEPARTMENT RECORD," dated 3/27/12, an RN documented Patient #18 received Tylenol 1000 mg. at 12:25 PM. The "Emergency Department Orders," form completed and signed by the physician did not indicate Tylenol was ordered. In addition, the "Emergency Department Orders," contained orders for laboratory blood tests, a CT scan, and ultrasound, but were not timed by the physician.
During an interview on 4/18/12 at 2:30 PM, the Director of Quality and Risk Management reviewed Patient #18's record and confirmed the orders were not timed, as well as the lack of written order for Tylenol.
The untimed orders lacked clarity as to when the physician ordered the tests and procedures and when they were completed.
00023
4. Patient #7's medical record documented a 31 year old female who presented to the ED on 4/12/12 at 8:53 AM. The EDR stated Patient #7's chief complaint was "migraine." The triage section of the EDR stated "Pt was seen in [physician office] & given Amlopidine [a blood pressure medication] & has been nauseated." The triage section of the EDR also stated her blood pressure was elevated. The "Triage Acuity" section stated Patient #7 was classified as "Semi-urgent." It was not clear how this classification was determined since no assessment or vital signs were documented.
Patient #7's EDR contained a section labeled "PRIMARY ASSESSMENT" which documented an assessment by the RN beginnig at 10:10 AM. It stated Patient #7 had vomited and her pain level was 7-8 of 10. A check indicated a neruological assessment was within defined limits, or normal. Her blood pressure was 158/126.
The EDR docuemented the physician examined Patient #7 beginning at 10:30 AM on 4/12/12. The "ED Physician/LIP Report," dated 4/12/12 at 12:36 PM, diagnosed Patient #7 with headach and "Hypertension, which could be related to each other." Patient #7 was treated with IV fluids, IV narcotic pain medication, and IV anti-nausea medication.
Patient #7 was discharged home at 12:48 PM. Nursing notes stated her pain level had decreased to 2/10. Her blood pressure continued to be very high, however. The last documented blood pressure was dated 4/12/12 at 12:51 PM. It was 172/128.
The RN who cared for Patient #7 was interviewed on 4/18/12 beginning at 8:05 AM. She reviewed the EDR. She stated Patient #7 had presented to the ED at 8:53 on 4/12/12. She stated she had come to the window in the reception area and talked with Patient #7. She stated Patient #7 compained of a headache and said her blood pressure was high. The RN stated Patient #7 had an appointment with her primary care physician off site at 9:15 AM but her headache was very painful so she came to the ED for treatment. The RN stated the ED was busy so Patient #7 was told it would be faster if she left and went to the appointment with her primary care physician. The RN stated Patient #7 left the ED and went to her physician appointment and returned later that morning. The RN confirmed Patient #7s request to leave and subsequent departure and return were not documented.
Patient #7's medical record was not complete.
5. Patient #22's medical record documented a 30 year old female who presented to the ED on 3/15/12 complaining of left ear pain. The time of her arrival was not documented. A set of vital signs was documented at 10:32 PM on 3/15/12. Except for the vital signs, no contact with an RN was documented. No triage assessment was documented. No triage acuity level was documented. No examination by a physician was documented. A form, "REJECTION OF TREATMENT/LEAVING AGAINST MEDICAL ADVICE," dated 3/15/12, was signed by Patient #22 and an RN. The time it was signed was not documented. An "ED Nurse Visit Note," dated 3/16/12 at 1:00 AM, stated Patient #22 left without treatment because the wait was too long. No other documentation was present to explained the course of events for Patient #22.
The medical record for Patient #22 was reviewed with the ED Manager on 4/18/12 beginning at 11:40 AM. She confirmed the lack of documentation in Patient #22's record.
Patient #22's medical record was not complete.
6. Patient #23's medical record documented a 58 year old male who presented to the ED on 3/15/12 at 11:18 PM complaining of leg pain. No documentation was present to show Patient #23 was triaged or otherwise assessed by an RN. No examination by a physician was documented. No documentation of any care provided to patient #23 was present. A form, "REJECTION OF TREATMENT/LEAVING AGAINST MEDICAL ADVICE," dated 3/15/12, was signed by Patient #23 and an RN. The time it was signed was not documented. The form stated Patient #23 decided not to wait and went to another emergecny room.
The medical record for Patient #23 was reviewed with the ED Manager on 4/18/12 beginning at 11:40 AM. She confirmed the lack of documentation in Patient #23's record.
Patient #23's medical record was not complete.