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Based on interview and record review, the hospital failed to ensure the patient's family was informed of the treatment plan regarding to using midazolam (aanxiolytic) for cast removal and re-suturing for one of four sampled patient (Patient 1). This failure posed the increased risk for the patient's family member not to understand the planned procedure's risk and problems that might be encountered during the procedure.

Findings:

Review of the hospital's P&P titled Patient Rights and Responsibilities dated 2/24/22, showed the following:

* Policy:

- Patient's Rights and Responsibilities: Receive information about your health status, diagnosis, prognosis, course of treatment, prospects for recovery and outcomes of care (including unanticipated outcomes) in terms you can understand. You have the right to effective communication and to participate in the development and implementation of your plan of care; participate in ethical questions that arise in the course of your care, including issues of conflict resolution, withholding resuscitative measures, and forgoing or withdrawing life-sustaining treatment.

On 11/6/24 at 1137 hours, an interview and concurrent review of Patient 1's medical record was conducted with the Director of Regulatory Affairs, Director of Emergency Services, and ED Clinical Nurse Specialist.

Patient 1's medical record showed Patient 1 was admitted in the ED on 10/6/24 at 1149 hours, for the splint or cast check.

Review of the ED Note-Physician dated 10/6/24, showed at 1327 hours, Medical Provider 3 saw Patient 1. The Physical Examination section showed the cast to the left lower extremity was cracked above the ankle, cast material on the right toes was swelling apart, and cast on the left upper extremities was intact. The Differential Diagnosis section showed Patient 1 encountered for the cast take down and repair. The medical decision making would consult the plastic surgery for recasting. The Re-examination/Re-evaluation sections showed at 1543 hours, the Plastic Surgery (Medical Provider 2) consult was at the bedside to replace the cast; at 1606 hours, attempted to replace the cast under Versed (same as midazolam), Patient 1 was unable to tolerate procedure, and would perform conscious sedation under ketamine (anesthetic). The Disposition section showed Patient 1 care was transitioned to Medical Provider 5.

Review of the ED orders showed to midazolam 3.3 mg/0.66 ml inj. nasal one time, stat, start on 10/6/24 at 1332 hours and stop at 1332 hours.

Review of Medical Provider 4 note dated 10/6/24, showed at 1628 hours, Patient 1 was re-examined or re-evaluated. Medical Provider 2 was at the bedside. Patient 1 was unable to tolerate suture of wound and casting with intranasal Versed. Medical Provider recommended IV line for procedural sedation with ketamine.

Review of Patient 1's MAR showed midazolam 3.3 mg/0.66 ml intranasal one-time stat was administered for the patient on 10/6/24 at 1529 and 1642 hours.

Review of the Medical Provider 2 note dated 10/16/24, showed consultation for cast falling off. There was no documentation Patient 1's family member was informed of the treatment plan of cast removal and use of Versed via inhalation.

On 11/6/24 at 1355 hours, the Director of Regulatory Affairs, Director of Emergency Services, and ED Clinical Nurse Specialist was asked to show Patient 1's family member was informed of the planned treatment cast removal with the use of Versed inhalation. The ED Clinical Nurse Specialist could not show documented evidence Patient 1's family member was informed of the planned treatment of cast removal with the use of Versed.

Based on observation, interview, and record review, the hospital failed to ensure the patients received care in the safe setting as evidenced by:

1. The hospital staff failed to ensure the hospital's P&Ps were implemented for one of four sampled patients (Patient 1) as evidenced by:

a. The ED RN failed to perform the initial assessment for the patient as per the hospital's P&P.

b. The ED RN did not perform the focused reassessments every two hours for the patient as per the hospital's P&P.

c. The ED RN failed to ensure the patient was assessed before and after the pain medication was administered as per the hospital's P&P.

d. The ED RN failed to ensure the patient was monitored when the midazolam medication was administered as per the hospital's P&P.

e. Medical Provider 2 failed to ensure Patient 1 received adequate pain medication during the procedure when the LLE flap was sutured during the bilateral cast removal and replacement procedures.

f. Medical Provider 2 failed to ensure the treatment plan was discussed with the attending physician prior to the suture repair, casting bilateral lower extremities with procedural sedation treatment plan for Patient 1.

2. Medications found unsecured in the ED.

These failures posed an increased risk of substandard health outcomes for the patients.

Findings:

1. Review of the hospital's P&P titled Patient Rights and Responsibilities dated 2/24/22, showed the patients and their guardians or caregivers have the rights to:

- Considerate and respectful care, and to be made comfortable. You have the right to expect respect for your cultural, psychosocial, spiritual, personal values, beliefs, and preferences.

- Appropriate assessment and management of your pain, information about pain, pain relief measures and to participate in pain management decisions. You may request or reject the use of any modalities to relieve pain, including opiate medication, if you suffer from severe chronic intractable pain. The doctor may refuse to prescribe the opiate medication, but if so, must inform you that there are physicians who specialized in the treatment of severe chronic pain with methods that include the use of opiates.

Review of the hospital's Emergency Department Standards of Care dated 8/26/24, showed in part:

* Standard of Care Overview: Standards of Care define nursing practice and the minimum care a patient can expect to receive during their stay in the ED. The RN is responsible for standards of care delivery, which can be delegated to appropriate clinical staff within their scope of practice.

* Standard 1: Assessment

- The RN collects comprehensive data to the patient's health and or the situation.

- Patients will receive an initial assessment, which includes a head-to-toe examination. Findings will be documented in the medical record.

- Reassessments are focused on abnormal findings or problems identified in the initial assessment, changes in clinical status, interventions or procedure, and evaluations or response to intervention or treatment. All reassessments must be documented. Reassessments are performed and documented based on ESI score outlined under assessment and reassessment in the ED: ESI 3, every 2 hours.

- Pain is assessed using age-appropriate pain scale. A documented intervention is required for pain score of 4 or greater.

- A pain score is reassessed within 1 hour after an intervention, with ongoing assessment and intervention as needed.

* Standard 4: Planning

- Patient or Family Education takes place throughout the emergency department visit. Education includes the plan of care and medication side effects, benefits, and dosage.

* Standard 5: Implementation

- Vital Signs are documented based on the patient's ESI: ESI 3 every 2 hours.

- Cardiopulmonary monitoring is used to evaluate the patient's heart and respiratory rate or rhythm determination.

* Standard 6: Evaluation

- Ongoing Assessments: Subsequent focused assessments will be completed and documented and documented every 2 hours or more frequently as needed.

- Pain is assessed and documented utilizing age and developmentally appropriate pain scale every 2 hours or more frequently as indicted by condition.

- Provide patient or family preferred pain management intervention for procedural pain, when appropriate.

* Standard 9: Communication

- The RN communicates effectively in all areas of professional practice.

On 11/6/24 at 1137 hours, an interview and concurrent review of Patient 1's medical record was conducted with the Director of Regulatory Affairs, Director of Emergency Services, and ED Clinical Nurse Specialist.

Patient 1's medical record showed Patient 1 was admitted in the ED on 10/6/24 at 1149 hours, for the splint or cast check. Patient 1 was assessed with ESI level 3 (urgent). The patient was discharged on 10/6/24 at 1950 hours.

a. Review of the ED RN initial assessment for Patient 1 was conducted with the Director of Emergency Services and ED Clinical Nurse Specialist. The Director of Emergency Services and ED Clinical Nurse Specialist was asked to show the initial head to toe nursing assessment for Patient 1. The Director of Emergency Services and ED Clinical Nurse Specialist stated there was no documented head to toe assessment for the patient. The Director of Emergency Services stated at 1206 hours, the Triage Nurse performed a nursing assessment. However, there was no initial assessment of head to toe documented.

b. Review of the ED RN reassessment for Patient 1 was conducted with the Director of Emergency Services and ED Clinical Nurse Specialist.

The Director of Emergency Services and ED Clinical Nurse Specialist was asked to show the ED RN's documentation of Patient 1's focused reassessment every 2 hours. The Director of Emergency Services and ED Clinical Nurse Specialist stated there was no focused reassessment for Patient 1 performed every 2 hours.

c. Review of the hospital's P&P titled Pain Management dated 9/23/21, showed the following:

* Policy: All patients have the right to have their pain managed using a multimodal approach of pharmacological and non-pharmacologic measures. All treatment is based upon behavioral and psychological parameters reported by staff, the patient and/or caregiver. Pain assessments are completed upon admission, per unit standards, at the time of transfer, or more frequently as indicated by patient condition. Goal of pain treatment or intervention should be a pain score of 3 or less or a decrease in the pain score. The hospital utilizes the pain assessment scales including Faces, Legs, Activity, Cry, Consolability (revised FLACC) that is appropriate for patients 2 months to 7 years of age, for non or preverbal patients, patients that are sedated or developmentally delayed of any age.

* Assessment:

- Utilize pain assessment tool or ask the patients if they are in pain; accept their subjective report of pain.

- Be sure to assess patient's pain when they are moving, not just when lying in bed or sitting on a chair.

- Assess site of patient's pain or discomfort. Include inspection, palpation, and range of motion of involved joints if applicable. Assess for physical, behavioral, and emotional signs and symptoms of pain, including moaning, crying, whimpering, vocalization, decrease activity, change in usual behavior, facial expression, guarding body part, muscle tension, restlessness, exhaustion, abnormal gait, diaphoresis. irritability or change in mental status especially confusion or agitation, which may be a sign of unrelieved pain, anxiety and fear can lead to elevated pain perception.

* Reassessment:

- Reassess initial pain score of 4 or more, within 30 minutes for IV analgesics, or within 1 hour for oral analgesics or non-pharmacologic interventions for effectiveness.

- A repeat pain score of 4 or greater requires the start of another Pain Air cycle with intervention and reassessment within 1 hour of current elevated pain score.

- Evaluate for presence of analgesic side effects (such as excessive somnolence, respiratory depression, nausea and vomiting).

* Documentation:

- Patient and caregiver education.

- Pain scale used for pain assessment.

- Pain assessment including rating, at minimum of every 4 hours, and after each intervention.

- Vital signs and SpO2, if ordered.

- Pharmacologic and non-pharmacologic interventions provided in response to increase pain score.

On 11/6/24 at 1355 hours, interview and concurrent review Patient 1's record was conducted with the Director of Emergency Services and ED Clinical Nurse Specialist.

Review of the ED Note-Physician dated 10/6/24, showed at 1327 hours, Medical Provider 3 saw Patient 1. The Physical Examination section showed the cast to the left lower extremity was cracked above the ankle, cast material on the right toes was swelling apart, cast on the left upper extremities was intact. The Differential Diagnosis showed Patient 1 encountered for cast take down and repair. The medical decision making was to consult plastic surgery for recasting. The re-examination/Re-evaluation sections showed at 1543 hours, Medical Provider 2 consult was at the bedside to replace the cast; at 1606 hours, attempted to replace cast under Versed, Patient 1 was unable to tolerate the procedure, and conscious sedation under ketamine would be performed. The Disposition section showed Patient 1 care was transitioned to Medical Provider 5.

Review of the ED orders showed to administer acetaminophen-hydrocodone bitartrate (narcotic analgesic) 3 mg/6 ml elixir oral one-time stat, starting on 10/6/24 at 1401 hours.

Review of Patient 1's MAR showed the patient received acetaminophen-hydrocodone (Lortab) 3 mg/6 ml elixir oral on 10/6/24 at 1416 hours.

On 11/6/24 at 1427 hours, during an interview with the Director of Emergency Services and ED Clinical Nurse Specialist, the Director of Emergency Services and ED Clinical Nurse Specialist was asked to show evidence of the ED RN documentation for monitoring Patient1's pain before and after pain medication was administered. The Director of Emergency Services and ED Clinical Nurse Specialist stated there was no documentation the ED RN monitored the patient pain scale before and after the pain medication was administered for the patient.

d. Review of the hospital's P&P titled Intranasal Medication (INM) Administration for Anxiolysis dated 12/8/22, showed the following:

* Policy: intranasal medications that may be ordered for procedural anxiolysis or minimal sedations, may include midazolam. A provider order is required for INM. A RN may administer intranasal medication.

* Procedure:

- Ensure the six rights of medication safety.

- Prior to administration, attach cardiorespiratory monitor, pulse oximetry, and blood pressure cuff to patient; and obtain baseline vital signs (BP, HR, RR, and O2 saturations).

- Monitoring: Continuously monitor patient's HR, RR, pulse oximetry during administration and for 1 hour post administration; obtain vital signs at the time of administration, 15 minutes post administration, 1 hour post administration, and prior to discontinuing continuous monitoring.

- Document in the medical record the medication administration, vital signs, and any procedural complications.

Review of the ED Note-Physician dated 10/6/24, showed at 1327 hours, Medical Provider 3 saw Patient 1. The Physical Examination section showed the cast to the left lower extremity was cracked above the ankle, cast material on the right toes was swelling apart, cast on the left upper extremities was intact. The Differential Diagnosis showed Patient 1 encountered for cast take down and repair. The medical decision making was to consult plastic surgery for recasting. The re-examination/Re-evaluation sections showed at 1543 hours, Medical Provider 2 consult was at the bedside to replace the cast; at 1606 hours, attempted to replace cast under Versed, Patient 1 was unable to tolerate the procedure, and conscious sedation under ketamine would be performed. The Disposition section showed Patient 1 care was transitioned to Medical Provider 5.

Review of Medical Provider 4 note dated 10/6/24, showed at 1628 hours, Patient 1 was re-examined or re-evaluated. Medical Provider 2 was at the bedside. Patient 1 was unable to tolerate suturing of wound and casting with intranasal Versed. Medical Provider 2 recommended IV line for procedural sedation with ketamine.

Review of the orders showed to administer midazolam 3.3 mg/0.66 ml nasal one-time stat starting on 10/6/24 at 1332 and 1556 hours.

Review of Patient 1's MAR dated 10/6/24, showed midazolam 3.3 mg/0.66 ml (IN) intranasal was administered to the patient at 1529 hours and 1642 hours.

On 11/6/24 at 1530 hours, the Director of Regulatory Affairs, Director of Emergency Services, and ED Clinical Nurse Specialist was asked to show documented evidence Patient1's monitoring when the midazolam was administered to the patient during the procedure of cast removal. The ED Clinical Nurse Specialist stated there was no vital signs monitoring for the patient during the administration of midazolam. The ED Clinical Nurse Specialist was asked if Patient 1 attached to a cardiorespiratory monitor. The ED Clinical Nurse Specialist stated no, he could not find documentation to show the patient was attached to a cardiorespiratory monitor.

e. Review of the hospital's P&P titled Procedural Sedation/Analgesia by Non-Anesthesiologists dated 1/17/23, showed the following:

* This policy applies to all qualified providers who order, administer, or supervise sedation.

* Analgesia involves the use of a medication to provide relief of pain of pain through the blocking of pain receptors in the peripheral and or central nervous system. The patient does not lose consciousness but does not perceive pain to the extent that may otherwise prevail.

* Sedation: minimal, moderate or deep sedation or analgesia unless otherwise specified. Summary of moderate sedation levels are as follows:

Responsiveness: purposeful response to verbal or tactile stimulation.
Airway: No intervention required.
Spontaneous Ventilation: Adequate
Cardiovascular functions are usually maintaining.

* Moderate Sedation: Sedation Level 2, a drug-induced depression of consciousness during which patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation (reflex withdrawal from a painful stimulus is not considered purposeful response). No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Review of Appendix B, Sedation and Analgesia Dosing Guidelines (for Procedural Sedation) showed for ketamine, consider a benzodiazepine (anti-anxiety) with ketamine and an anti-secretory for pediatrics, 0.005 mg/kg IM or IV.

Review of the RN's Flowsheet documentation for Patient 1's Suture Repair, Casting with Procedural Sedation Casting bilateral lower extremities, monitoring using ketamine IV showed the following:

- At 1801 hours, the patient's O2 saturation was 95%. The artificial airway management section showed the RT performed bag or valve ventilation, and the RT assessment was completed.

- At 1802 hours, the procedure was started. Ketamine 14 mg IVP was given for Patient 1. The patient's HR was 118 bpm. The patient's RR was 25 breaths per minute. The patient's O2 saturation was 94%. The patient's ETCO2 was 49 mmHg (normal range is 35 - 45 mmHg). The patient's sedation scale was 3 (drowsy). The patient's skin color assessment had circumoral cyanosis.

- At 1803 hours, the patient's O2 saturation was 95 %.

- At 1805 hours, the patient's O2 saturation was 91 %. The procedural sedation scale was 2 (slightly drowsy, easily aroused).

- At 1807 hours, the patient's HR was 132 bpm. The patient's RR was 30 breaths per minute. The patient's O2 saturation was 74%. The patient's ETCO2 was 51 mmHg (high). The procedural sedation scale was 2.

- At 1810 hours, the patient's HR was 128 bpm. The patient's RR was 16 breaths per minute. The patient's O2 saturation was 98%. The patient's ETCO2 was 45 mmHg. The procedural sedation scale was 2.

- At 1815 hours, the patient's HR was 164 bpm. The patient's RR was 22 breaths per minute. The patient's O2 saturation was 93%. The patient's ETCO2 was 40 mmHg. The FLACC assessment was 7; and the patient had frequent to constant quivering chin, clenched jaw, kicking, squirming, crying steadily, and content. The procedural sedation monitoring sedation score was 1 (awake and alert). The patient's skin color was pink.

- At 1820 hours, the patient's HR was 177 bpm. The patient's RR was 24 breaths per minutes. The patient's O2 saturation was 95% breaths per minute. The patient's ETCO2 was 26 mmHg (low). The procedural sedation score was 1 (awake and alert).

- At 1825 hours, the patient's HR was 167 bpm. The patient's RR was 24 breaths per minute. The patient's O2 saturation was 96%. The patient's ETCO2 was 32 mmHg. The procedural sedation score was 1.

- At 1830 hours, the patient's HR was 172 bpm. The patient's RR was 21 breaths per minute. The patient's O2 saturation was 96%. The patient's FLACC Score was 8; the patient was frequent to constant quivering chin, clenched jaw, kicking, squirming, crying steadily, difficult to console or comfort. The patient's ETCO2 was 42 mmHg. The procedural sedation score was 1.

- At 1900 hours, the patient's FLACC score was 8 and the patient had frequent to constant quivering chin, clenched jaw, kicking, squirming, crying steadily, difficult to console, or comfort.

- At 1920 hours, the patient's FLACC score was 0; no particular expression, normal position, relaxed, moves easily, no cry, content.

The Director of Emergency Services and ED Clinical Nurse Specialist was asked what the goal level for moderate sedation was. The ED Clinical Nurse Specialist stated the goal was 2. The ED Clinical Nurse Specialist was asked what the sedation level score of 1 was. The ED Clinical Nurse Specialist stated the sedation level 1 was the baseline when the patient was awake and alert.

On 11/7/24 hours at 1655 hours, an interview and concurrent record review was conducted with ED RN 3, the Director of Regulatory Affairs, Director of Emergency Services and ED Clinical Nurse Specialist. ED RN 3 was asked about the monitoring of the procedural sedation for Patient 1. ED RN 3 stated Patient 1 became hypoxic and had cyanosis on his face when Medical Provider 4 gave the patient ketamine IV. RT 1 and the Medical Provider 4 ventilated Patient 1 by ambubag. Medical Provider 4 repositioned the patient. The RT and Medical Provider 4 held the head while ambubagging the patient. Jaw thrust maneuver was performed but she could not remember who performed the jaw thrust. ED RN 3 stated Medical Provider 5 was called and said not to give anymore ketamine and if the patient could not complete the procedure the patient had to go to OR.

On 11/7/24 at 1307 hours, a telephone interview was conducted with Medical Provider 4, the Director of Regulatory Affairs, Director of Emergency Services and ED Clinical Nurse Specialist. Medical Provider 4 was asked about the procedural sedation for Patient 1. Medical Provider 4 stated she was at the procedural sedation for Patient 1's resuturing and cast replacement, she administered the ketamine IV and made sure the patient's airway, cardiovascular function, and vital signs were ok. Medical Provider 4 stated Medical Provider 5 was called in the room and did not want to give anymore ketamine IV to the patient. Medical Provider 4 was asked about sedation level 1 and FLACC 7/pain assessment for Patient 1 while the suturing and cast replacement procedure was being done. Medical Provider 4 stated Medical Provider 2 performed the suturing and cast replacement and that should be a question for her.

On 11/7/24 at 1601 hours, an interview and concurrent record review was conducted with Medical Provider 1, Medical Provider 2, and the Director of the Regulatory. Medical Provider 2 was asked about the flap resuturing and replacement of bilateral cast procedure performed for Patient 1. Medical Provider 2 stated she gave Patient 1 lidocaine (a local anesthetic) j-tip and documented the list of the medications on her notes. However, she did not document she gave lidocaine for the patient during the procedure.

f. Review of the hospital P&P titled Roles and Supervision of Medical Student dated 3/28/19, showed the following:

* Definitions:

- Residents and Fellows: Physicians who are engaged in graduate medical education in pediatric medicine and who participate in patient care under the supervision of the attending physicians and licensed independent practitioners. Residents and fellows are responsible for asking for help from the supervising physician or appropriate licensed practitioner for the service they are rotating on when they are uncertain of diagnosis, how to perform a diagnostic or therapeutic procedure, or how to implement an appropriate plan of care.

- Attending: An identifiable, appropriately-credentialed and privileged attending physician or licensed independent practitioner who is ultimately responsible for the management of the individual patient and for the supervision of the residents and fellows involved in the care of the patient. The attending delegates portions of care to residents and fellows based on the needs of the patient and the skills of the residents and fellows.

* Policy: Clinical responsibilities: Residents and fellows are part of a team of providers caring for patients. The team includes an attending and may include other licensed independent practitioners, other trainees and medical students. Residents and fellows may provide care in both the inpatient and outpatient settings. They may serve on a team providing direct patient care, or may be part of a team providing consultative or diagnostic services. Each member of the team is dedicated to providing excellent patient care.

- Resident and fellows evaluate patients, obtain the medical history and perform physical examinations. They may develop a differential diagnosis and problem list. Using this information, they develop a plan of care in conjunction with other trainees and the attending. They may participate in procedures performed at the bedside, in the OR or procedure suite under appropriate supervision. They may participate in prescription of orthoses and prosthesis with attending supervision. Residents and fellows should discuss the patient's status and plan of care with the attending and the team regularly. All residents and fellows help provide for the educational needs and supervision of any junior residents and medical student.

* Procedure: In all cases, the attending physician is ultimately responsible for the provision of care by residents and fellows. When there is any doubt about the need for supervision, the attending should be contacted.

* Supervision of Consults: Residents may provide consultation services under the direction of supervisory residents including fellows. The attending of record is ultimately responsible for the care of the patient and thus must be available to provide direct supervision when appropriate for optimal care and or as indicated by individual program policy.

Review of the hospital's Medical Staff Rules and Regulation dated October 2021 showed the following:

* Policy on Supervision of Residents

- Each resident is responsible for communicating to their attending physician significant issues as they relate to patient care. Such communication must be documented in the record. All outpatients in the ED and clinics for which the attending physician is responsible should be seen by or discussed with, the attending physician at that initial visit. This must be documented in the chart via a progress note by the attending physician or reflected in the resident's note to include the name of the attending physician and the nature of the discussion. All notes must be signed and dated.

Review of Medical Provider 2's outpatient note for Patient 1 showed visit date was 10/6/24. The Physical Exam section showed "RLE: cast with cracks and bite marks at the toes, removed, suture line appears intact with some bleeding/oozing during examination while the patient was thrashing about...LLE: cast with circumferential defect around the ankle, mobile, when removed there is oozing from the dorsal flap site with damaged sutures and nearly free dorsal flap." The Assessment/Plan section showed status post conscious sedation procedure and suturing of the LLE, cast removal and replacement of the bilateral lower extremities.

On 11/7/24 at 1601 hours, an interview and record review was conducted with Medical Providers 1 and 2, and the Director of Regulatory Affairs. Medical Provider 2 was asked if she discussed the planned treatment for Patient 1 with her attending, the planned treatment using midazolam for cast removal, resuturing of skin flap, and the procedural sedation for resuturing, and casting of bilateral lower extremities. Medical Provider 2 stated she sent her progress notes to the plastic attending on the day of the procedure. However, the documentation did not show the procedures performed for Patient 1 were discussed with the attending. Medical Provider 1 stated the practice with his residents, the residents would discuss with him the plan of care and he would redirect the residents accordingly.

The findings were verified and shared with the Director of Regulatory Affairs.


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2. Review of the hospital's P&P titled Storage and Security of Medications dated 1/28/21, showed under section I, Purpose: To establish a safe and effective system for the storage and security of medications and chemicals, in accordance with Stated and Federal regulations. Medications will be secured in locked storage areas and accessible only to authorized hospital personnel.

On 11/6/24 at 1022 hours, a tour of the ED was conducted with the Director of Emergency Services and ED Clinical Nurse Specialist. During the walkthrough and observation of the department, two prefilled syringes of lidocaine 4mg/0.4ml were observed left unattended in the nurse's work cubby located near exam room 19. Exam room 19 was observed to be occupied by a patient. When asked the purpose of the syringes, the ED Clinical Nurse Specialist stated the lidocaine was used to numb the area where an IV line was placed on a patient. When asked if the medication should have been left unsecured, the Director of Emergency Services stated no.

On 11/7/24 at 1650 hours, the Director of Regulatory Affairs was notified of the findings.