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Based on observation, interview and record review, the facility 1. failed to protect patient rights for 1 of 10 patients (P-2) reviewed for patient rights, from a total of sample of 10, resulting in pain and delay of care of P-2 and the potential for poor outcomes for all patients and 2. failed to develop and implement a policy that protected patients from abuse while under the care of the facility, resulting in the potential for unsatisfactory outcomes for all patients served by the facility

Findings include:

A-145: Failure to protect patients from abuse and neglect.

Based on observation, interview and record review, the facility failed to 1. Ensure patients were free from neglect for 1 (P-2) of 10 patients reviewed for patient rights from a total of 10 patients, resulting in pain and delay of care of P-2 and the potential for poor outcomes for all patients and 2. develop and implement a policy that protected patients from abuse while under the care of the facility, resulting in the potential for unsatisfactory outcomes for all patients served by the facility.
Findings include:

1.
In an interview on 10/04/2024 at 1125 P-2 stated she presented to the emergency department of the facility on 08/13/2024 with severe abdominal pain and the feeling of having a high fever with chills. The waiting room wasn't busy, the nurse called her to the triage room to get her vitals within about 20 minutes then sent her back to the waiting room. About 30 minutes later a resident physician came, took her to a room, did a brief and exam then left stating she was going to get the doctor. P-2 said the doctor came in about 15 minutes later, around 9:00 pm, said he thought it was her appendix, and even though they were down for computer issues, they would get everything started like IV (intravenous) pain medications, antibiotics, and a CT (radiology scan). The doctor left the room and nobody came back for hours. P-2 stated her pain was severe, she was shaking with chills, and felt like she was going to die. P-2 said around 11:20 pm a nurse came in and said, "Oh somebody is in here". The nurse stated to P-2 that staff were not aware she was in the room. Around 11:30pm she finally received pain medications and her IV. She said she was taken to her CT scan around 2:00 am.

Review of P-2's medical record on 10/08/2024 at 1330 revealed she was a 58-year-old female who presented to the emergency department on 08/13/2024 at 2010 for complaints of abdominal pain. Review of RN (Registered Nurse) triage note dated 08/13/2024 at 2026 indicated P-2 complained of right lower quadrant abdominal pain for 2 days with nausea and vomiting. Vital signs (blood pressure 166/93, pulse 103, temperature 38.2, respirations 16, O2 100%) were obtained along with current medications and allergies. The triage note indicated P-2's ESI (Emergency Severity Index) was a 3 and did not reveal a pain assessment. Review of nursing documentation for pain assessment of P-2 revealed first assessment of pain for P-2 to be documented at 2330 as question on Emergency Department RN Patient Assessment form of "Do you have pain?" being circled Yes, with no further assessment. The next pain assessment documented is 08/13/2024 at 2355 on medication administration record with P-2 reporting pain as 10/10.

Review of physician orders for P-2 dated 08/13/2024 at 2156 indicated orders for 1 liter of normal saline bolus, 1,000 milligrams (mg) Tylenol by mouth (PO), 0.5 mg Dilaudid IV (intravenous) 4.5-gram Zosyn IV, Lactated Ringer 125 ml/hour and 4 mg morphine IV.
Review of laboratory orders for P-2 revealed on 08/13/2024 at 2332 there were orders for CBC (Complete Blood Count) without differential, complete metabolic panel, protime, lipase, magnesium, lactic acid, urinalysis, and type and screen.

Review of medication administration record for P-2 on 08/13/2024 revealed she received normal saline IV bolus 1000 ml at 2355 to 0100, acetaminophen 1,000 mg PO at 2355, (IV pain medication) 0.5 mg IV push at 2355, (antibiotic) 4.5 mg IV at 0200, Morphine 4 mg at 0415, lactated ringer solution at 125 milliliters/hour at 0415 and (antinausea medication) 4 mg IV at 0650.

Review of ECG (electrocardiogram) completed on 08/13/2024 at 2343 revealed rate of 123 sinus tachycardia with ST deviation and moderate T-wave abnormality, abnormal ECG.

Post-operative procedure note dated 08/14/2024 indicated diagnosis/findings of acute gangrenous appendicitis (inflammation with signs of necrotic tissue) with perforation with localized peritonitis with abscess.

In an interview on 10/08/2024 at 1605, Staff N (emergency department RN) said she recalled P-2 and provided care for P-2 on 08/13/2024. Staff N stated P-2 was somehow put in the room where midlevel providers see patients and the door was closed. Staff N confirmed P-2 was forgotten. Staff N also confirmed when a patient presents for triage pain should be assessed, including a pain scale.

In an interview on 10/09/2024 at 1135, Staff K (ED RN who was identified as the nurse who triaged P-2) confirmed that it was her handwriting on the nursing triage form for P-2. Staff K said she did not recall P-2 or her being left in the midlevel room. Staff K reviewed her nursing triage note and stated she did not document an assessment of P-2's pain. When queried how she decided P-2 was an ESI 3, Staff K stated based on the resources P-2 would need labs and a scan. When asked if that would make P-2 an ESI level 3, Staff K stated she wasn't sure, maybe a high 3 or a 2.

In an interview on 10/08/2024 at 1530, Staff P (ED physician who provided care for P-2) stated he did not recall P-2. He said he wasn't sure why there would be several hours between the time he wrote his initial orders and the time the orders were administered. Staff P stated his expectation is that when he writes orders for the care of a patient it should be carried out promptly. Staff P said his practice is to examine the patient, then immediately place orders when he leaves the patient room, so the time of his orders would have been right after he left P-2's room. Staff P stated P-2 was febrile, with tachycardia and met SIRS (systemic inflammatory response syndrome) criteria (clinical criteria used to identify patients with systemic inflammation).

In an interview on 10/09/2024 at 1030, Staff B (Director of Patient Care Services Emergency Department) stated she was aware that P-2 and her spouse had reported a concern about a delay in care. The emergency department Manager had reported to Staff B they had resolved it. Staff B stated she was not made aware that P-2 was left in a room. There was no incident report completed, and no investigation was done. Staff B stated it is expected that patients have a pain assessment completed during triage.

On 10/09/2024 at 0945, review of the facility, "Triage of Patients in the Emergency Department" policy dated 07/19/2021 revealed 4.1 All patients presenting to the Emergency Department (ED) will be triaged and assigned an ESI score. 5.4. The Registered Nurse will initiate Nursing Quick orders, interventions and or diagnostics when appropriate based on patient's chief complaint and triage assessment. 5.5. Triage personnel will: 5.5.1 Alert the primary RN, charge RN and/or ED provider of any patient(s) requiring immediate attention. 5.5.2 Monitor, reassess, and update those patients that remain in the waiting room awaiting ED bed assignment. 5.5.3 Maintain communication with the ED charge nurse as applicable. 5.6. Once an ED bed becomes available, triage personnel will assign the patient to the room via the Tracking List and escort the patient to the treatment area..."

On 10/09/2024 at 0955, review of the facility, "Documentation of Vital Signs in the Emergency Department" policy dated November 17, 2023, revealed 1.1. Staff will obtain appropriate vital signs on all patients presenting to the Emergency Department (ED) based on the Emergency Severity Index (ESI). 1.1.2. ESI level 2: Vital signs taken at least every hour for the first 4 hours, then every 2 hours if clinically stable.

On 10/09/2024 at 0955, review of the facility, "Pain assessment/Reassessment" policy dated February 13, 2023, revealed, 2.1. The RN should assess the patient for pain and history of pain during the initial assessment and document findings.

According to the Emergency Severity Index Handbook (Version 5, Emergency Nurses Association, 2023) the ESI Triage Algorithm, Severe pain/distress, Heart rate greater than 100, with multiple resources would indicate P-2 was an ESI 2.

Emergency Nurses Association. (2023). Emergency severity index handbook fifth edition. (12).

2.
On 10/09/2024 at 1145, the surveyor requested the facility abuse policy. The surveyor was provided the facility's policies for reporting suspected abuse of adult and child when presenting for care at the facility. On 10/10/2024 at 0830, the surveyor sent an email to Staff I (Chief Nursing Officer) and again requested the policy detailing the hospital wide abuse prevention, screening, recognition, training, and reporting, protecting, and investigation of abuse policy.

Staff I (Chief Nursing Officer) sent an email to the surveyor on 10/10/2024 at 3:13 pm. The email included the facility's "Workplace Threats and Violence" and "Safety Event Classification & Event Management" policies. Staff I indicated the facility had no policy that directly details abuse and neglect of patients from a staff member.