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Based on review of facility policy, review of facility document, medical record review, review of video recording, and interview, the facility failed to provide care in a safe setting for 1 patient (#1) of 3 patients reviewed for abuse of 5 medical records reviewed.

The findings included:

During the investigation it was found one patient (#1) was admitted to the Emergency Department (ED) on 6/18/17 at 1:21 PM with a chief complaint of Alcohol (ETOH) Intoxication. The patient was triaged in the ED hallway and then was moved by the ED charged nurse at 1:33 PM to a vestibule area located between 2 sets of automatic sliding doors. The area was the entrance used by emergency medical services (EMS), was not a patient care area, and the patient could not be visualized from the Nurses Station. The patient was given an injection of Geodon (antipsychotic medication) intramuscular (IM) and then placed on a portable blood pressure and pulse oximeter machine and was left in the EMS entrance area unattended until 4:20 PM (approximately 3 hours).

Based on review of facility policy, review of facility document, medical record review, review of video recording, and interview, the facility failed to provide care in a safe manner for 1 Patient (#1) of 3 patients reviewed for abuse of 5 medical records reviewed and failed to ensure facility staff received annual abuse prohibition training for 7 (Registered Nurse #1, #2, #5, #6, #7, #8, and #9) of 8 employees personnel files reviewed.

The findings included:

Review of facility policy "Detection of Abuse, Abandonment, Neglect, or Exploitation," last revised 2/12/16, revealed "...Tennova Healthcare strives to the best of its ability to prohibit and protect patients from real or perceived abuse, neglect...recognizes the patient's rights to be free from mental, physical, sexual, and verbal abuse, neglect, or exploitation..." Further review revealed "...definitions: emotional abuse: willful infliction of anguish, pain, or distress through verbal or non-verbal acts...this includes, but is not limited to, isolating or frightening an adult...intentional neglect: failure to meet the needs of the dependent elderly person...this includes, but is not limited to willfully withholding food or medication...abandonment: desertion of a vulnerable individual by anyone who has assumed care or custody of that person..." Further review revealed "...if the alleged abuse is a staff member...the employee should be sent home without pay pending the administrative investigation...information will be gathered from all employees with knowledge and/or observations regarding the alleged incident...department manager will review the incident in a timely manner...Human Resources and Risk Management will be consulted regarding the need to report the alleged incident to appropriate agencies...if alleged violation is verified, appropriate action will be taken which may include...dismissal of staff member...informing state licensure agencies..."

Review of facility policy "Detection of Abuse, Abandonment, Neglect, or Exploitation" last revised 2/12/16 revealed "...employees will receive training on the following at the time of orientation and annually thereafter: abuse and neglect...related reporting requirements..prevention of abuse...detection of abuse..."

Review of facility policy "Patient Rights and Responsibilities," last revised on 8/9/16, revealed "...Tennova places emphasis on the importance of respecting each patient's personal dignity, while providing considerate, respectful, and ethical care focused upon the patient's individual needs..."

Review of a facility document dated 6/21/17 revealed "...patient was brought to the ED via EMS. Patient was noted to be anxious and distressed. Patient medicated with Geodon and was placed into the vestibule of the EMS bay on a monitor...Pt. stretcher was noted to have a sign that read 'NPO [nothing by mouth]-please do not disturb-if you have questions, comments or concerns please see the charge nurse-thank you'..." Further review revealed "...pt. had no orders for NPO and visitors had been observed taking pictures of the sign..." Continued review of a written statement written by Registered Nurse (RN) (Charge Nurse/alleged perpetrator) revealed "...upon arrival [named patient] was screaming constantly for no obvious reason...was extremely loud and frightening to several patients and visitors...placed patient in an area with sliding glass doors...when [named patient] was more in control of himself he was placed directly in front of the charge nurse station...I realize my poor judgement in this particular incident. This was a mistake...I understand how the placement of the [named patient] could be viewed as negligent..."

Medical record review revealed Patient #1 was admitted to the ED on 6/18/17 at 1:18 PM with a diagnosis of Alcohol Intoxication and a history of chronic bilateral Subdural Hematoma's. Further review revealed the patient was discharged home from the ED on 6/18/17 at 10:20 PM.

Medical record review of an ED Nurses Note dated 6/18/17 at 1:21 PM revealed the patient arrived to the ED by ambulance. Further review revealed "...EMS [emergency medical services] states that patient was trying to run into traffic today and the KPD [Knoxville Police Department] had called EMS to transport patient to hospital for further evaluation. Transition of care: patient was not received from another setting of care..." Further review revealed the patient was triaged as an ESI [emergency severity index] Level 4 indicating the patient was non-emergent. Continued review revealed "...appears distressed. Behavior is anxious...denies pain..."

Medical record review of an ED Physicians Note dated 6/18/17 at 1:46 PM revealed "...presents to the ED via EMS ground with complaints of ETOH [alcohol] abuse. Erratic behavior prior to arrival tried to run into traffic the police called EMS to transport patient...was here earlier in the week on the 17th for similar complaints and has long standing history of chronic alcoholism with presentations for intoxicated behavior. He has strong odor of mouthwash denies drinking mouthwash screams loudly, he is unable to offer any particular chief complaint sitting up on the examining stretcher..." Further review revealed "...unable to obtain ROS [review of systems] due to altered mental status...vital signs reviewed...clinically intoxicated to the point of being out of control although not physically violent at presentation..."

Medical record review of an ED Nursing Assessment dated 6/18/17 at 1:53 PM revealed "...appears malnourished. Behavior is restless, uncooperative. Pt. [patient] screaming and uncooperative...airway is patent, respiratory effort is even, unlabored..."

Medical record review of an ED Nurses Note dated 6/18/17 at 2:12 PM revealed "...pain: reassessment: denies any pain at this time. Patient has not been educated on call light usage nor is the call light within patient's reach at this time as patient remains in hallway...patient awaiting diagnostics at this time...resting quietly, appears to be sleeping..."

Review of an ED Security Camera Video recording, with a secuirty officer, on 6/30/17 at 1:55 PM revealed the following:
* 6/18/17 1:33 PM: the patient was placed in the EMS entrance area, between 2 sets of automatic entrance doors by a nurse
* 6/18/17 1:34 PM: the nurse exited the area and left the patient unattended
* 6/18/17 1:37 PM: the ED Physician examined the patient in the EMS entrance area
* 6/18/17 2:03 PM: Nurse placed a portable cardiac monitor on the patient
* Further review of the video recording revealed several ED staff employees walked by the area where the patient was and the staff did not check on the patient or remove the patient from the EMS entrance area
* Further review of the video recording revealed the patient was taken back into the ED and placed in the hallway at approximately 4:40 PM (approximately 3 hours later).

Telephone interview with RN #1 revealed "...the patient was intoxicated and being loud...he was not combative and did not complain of thoughts of hurting himself..." Further interview revealed "...a few minutes later, [the charge nurse] got up from her chair and stated 'I can't take this anymore'...she was upset...said was going to take the patient..." Further interview revealed the charge nurse took the patient to the EMS entrance area and left the patient there for several hours with no supervision or monitoring. Further interview revealed the area is not an assigned patient care area in the ED. Further interview revealed "...the charge nurse had placed a sign on the patient's bed that said 'NPO do not disturb patient, any comments or concerns, see the charge nurse'..." Continued interview revealed "...[charge nurse] gave the patient an Geodon injection...she said she had the patient on a portable monitor...there is no way you can see the patient from the nurses station..." Further interview revealed RN #1did not remove the patient from the area.

Interview with RN #2 on 6/29/17 at 11:00 AM, in the ED exam room, revealed "...I heard a patient yelling...I went around the corner and saw a patient in between the EMS entrance doors and the ED entrance...this is not an area where patients are located or treated...I thought it was very odd...he was lying on a stretcher...there was a hand written sign on the stretcher that said 'NPO...do not disturb...any comments or concerns please see the charge nurse'...that is not a sign we would place on any stretcher..." Further interview revealed "...the charge nurse had also given the patient an injection of Geodon...there is no way the patient could be visibly viewed from the area he was in and at the nurses station..." Further interview revealed RN #2 did not remove the patient from the area.

Interview with ED Physician #1 on 6/29/17 at 3:20 PM, in the ED Hallway, revealed "...I assumed care of the patient after [Physician #2] handed the patient off during shift change...I heard a patient yelling and I thought it was coming from room 15...I walked back there and saw it was not coming from room 15 then I saw a patient in the EMS entrance bay...he was on a stretcher and was between the entrance doors...he was yelling..." Further interview revealed "...I went out and saw the patient...asked [charge nurse] what was going on...she told me the patient was yelling and disturbing the other patients and there was no other place to put the patient..." Further interview confirmed the EMS entrance bay was not an assigned patient care area. Further interview revealed Physician #1 did not remove the patient from the area.

Telephone interview with RN #4 on 6/30/17 at 8:55 AM revealed "...the patient was on a stretcher in front of the nurses station at shift change...he was sleeping..." Further interview revealed "...[charge nurse] talked about placing the patient in the EMS entrance area...she said the patient was being very loud and was disturbing the entire ED..." Continued interview confirmed the EMS entrance area is not an assigned area in the ED for patient care and there are no call lights in the area.

Interview with RN #5 on 6/30/17 at 9:20 AM, in the ED Exam Room, revealed "...the patient was placed in the EMS entrance bay...he arrived in the ED around 1:00 PM and the ED charge nurse placed the patient out there...this is not an assigned area in the ED for patient care...I have never seen a patient placed there..." Further interview revealed "...when he came in the ED he was triaged by another nurse and placed in a hallway stretcher...he was very intoxicated and was brought by EMS to the ED after he was found in the middle of a road...he comes to the ED very frequently with intoxication and most of the time all he wants is food and to sober up..." Further interview revealed "...the charge nurse told the primary nurse that she was going to assume the patient's care...she took the patient and placed him in the EMS entrance bay and told the staff the patient was her patient...he was there from that time until about 4:30 PM..." Further interview revealed RN #5 did not remove the patient from the area.

Interview with Patient Care Technician (PCT) #1 on 6/30/17 at 9:45 AM, in the ED Exam room, revealed "...[charge nurse] wanted a sign...she wanted the sign to say 'do not touch or feed the patient'...I told her I could not do that so she made the sign herself..." Further interview revealed "...the patient was very intoxicated and had tried to get up when he first came into the ED...[charge nurse] took the patient and placed him in the EMS entrance bay and left him there...she placed the sign on the patient's bed..." Further interview revealed "...there was one time he got up and tried to run but [charge nurse] caught him and put him back in the bed...she asked security to come and talk to him..."

Interview with ED Physician #2 on 6/30/17 at 10:05 AM, in the ED Exam room, revealed the physician provided care to the patient on 6/18/17. Further interview revealed "...he was very intoxicated when he arrived...EMS reported the patient was found in the middle of the road and was brought to the ED for evaluation...he was yelling but was not combative but was somewhat disruptive...he wanted to get up..." Continued interview revealed "...I ordered 10 mg [milligrams] of Geodon IM [intramuscular] for the patient to help calm the patient down...I did not see the patient after that..." Further interview revealed Physician #2 did not remove the patient from the area.

Telephone interview with ED Registration Clerk #1 on 6/30/17 at 10:25 AM revealed "...I saw the patient in the EMS entrance bay...he was lying on a stretcher...[charge nurse] told me if I saw the patient get off the stretcher that I should come and get her..." Further interview revealed "...we don't normally see patients assigned to that particular area for treatment..."

Interview with Security Officer #1 on 6/30/17 at 11:00 AM, in the security office, revealed "...the patient was yelling and screaming when he came in...[charge nurse] asked me if I would talk to the patient...he was in the EMS entrance area between the entrance doors...we do not normally see patients in that area..." Further interview revealed the security guard did not remove the patient from the area.

Interview with the Charge Nurse on 6/30/17 at 11:30 AM, in the ED Exam room, revealed "...this patient is a frequent visitor to the ED...he usually comes in very intoxicated but is not violent..." Further interview revealed "...he was very loud and screaming...we were not able to redirect the patient...I felt he was frightening the other patients in the ED...I took the patient to the EMS entrance area and placed the patient against the wall while he was on the stretcher...I told the registration clerk which is located right beside the entrance area to let me know if the patient tried to get up...we do not normally place patients in that area...there are no call lights located in the area..." Continued interview revealed "...I made a mistake..."

Interview with the ED Nurse Manager on 6/30/17 at 1:15 PM, in the conference room, revealed "...received a text on Sunday [6/18/17] with a picture of the patient's bed and the sign that was placed on the patient's bed..." Review of the text message revealed it was received on 6/18/17 at 7:29 PM and the message stated "...NPO-Please do not disturb-if you have questions, comments, or concerns please see the charge nurse...thank you..." Further interview revealed "...they told me on Tuesday [6/20/17] that the patient was placed in the EMS entrance area...I text [named Director of Nursing] that night [6/18/17] and told him about the sign business...he told me to do some investigation..." Continued interview revealed the ED manager had spoken with several ED employees about the incident and "...I sent a text to [named Director of Nursing] and told him about the situation...he advised me to do some investigation and we would need to talk with [charge nurse]..." Further interview revealed "...on 6/21/17 we spoke with [charge nurse]...she said the patient was very loud and disrupting to the entire ED and she was trying to keep the patients from hearing that...she said she placed the patient in the EMS entrance area..." Further interview revealed "...I do not know how long the patient stayed out there...he was moved back to [ED hallway stretcher]..." Continued interview confirmed the EMS entrance was not a patient care area and the facility failed to provide care in a safe setting.

Interview with the Director of Nursing (DON) on 6/30/17 at 1:45 PM, in the conference room, revealed "...the ED Manager text me on 6/19/17 at 9:09 AM and told me about the signage on the patient's stretcher...I told him to do some investigation and get some information...on 6/20/17 he told me about the patient being placed in the EMS entrance bay...I told him we needed to interview [charge nurse] that day..." Further interview confirmed "...this is unacceptable practice...it is inappropriate to place that kind of signage on a patient bed..." Further interview confirmed "...the charge nurse failed to act in a professional manner and failed to respect the patient's dignity..."

Interview with the Chief Nursing Officer (CNO) on 6/30/17 at 2:00 PM, in the conference room, confirmed the actions taken by the nurse were intimidating and the nurse failed to follow acceptable staff behavior by placing a sign on a patient's bed and moving the patient to an isolated area, which was not a patient care area.

Review of the personnel record for RN #1 revealed the nurse was hired on 10/13/14. Continued review revealed the nurse had no documentation of annual abuse or neglect training.

Review of the personnel record for RN #2 revealed the nurse was hired on 5/31/11. Continued review revealed the nurse had no documentation of annual abuse or neglect training.

Review of the personnel record for RN #5 revealed the nurse was hired on 8/3/15. Continued review revealed the nurse had no documentation of annual abuse or neglect training.

Review of the personnel record for RN #6 revealed the nurse was hired on 5/11/09. Continued review revealed the nurse had no documentation of annual abuse or neglect training.

Review of the personnel record for RN #7 revealed the nurse was hired on 6/1/09. Continued revirew revealed the nurse had no documentation of annual abuse or neglect training.

Review of the personnel record for RN #8 revealed the nurse was hired on 5/31/11. Continued review revealed the nurse had no documentation of annual abuse or neglect training.

Review of the personnel record for RN #9 revealed the nurse was hired on 4/16/12. Continued review revealed the nurse had no documentation of annual abuse or neglect training.

Interview with the Quality Manager on 6/30/17 at 10:00 AM, in the conference room, revealed "...as a part of the annual competency we have not assigned the Elder Abuse to the staff..." Further interview confirmed the nurses had not completed the annual abuse and neglect and the facility failed to follow facility policy.

Based on review of facility policy, medical record review, review of facility documentation, review of video recording, and interview, the facility failed to provide a nursing assessment for 1 patient (#1) who was intoxicated of 3 patients reviewed for abuse of 5 medical records reviewed.

The findings included:

During the investigation it was found one patient (#1) was admitted to the Emergency Department (ED) on 6/18/17 at 1:21 PM with a chief complaint of Alcohol (ETOH) Intoxication. The patient was triaged in the ED hallway and then was moved by the ED charged nurse at 1:33 PM to a vestibule area located between 2 sets of automatic sliding doors. The area was the entrance used by emergency medical services (EMS) and was not a patient care area and the patient cannot be visualized from the Nurses Station. The patient was given an injection of Geodon (antipsychotic medication) intramuscular (IM) and then placed on a portable blood pressure and pulse oximeter machine and was left in the EMS entrance area unattended until 4:20 PM (approximately 3 hours).

Based on review of facility policy, facility document review, medical record review, review of a security tape, and interview, the facility failed to provide appropriate and timely nursing care for 1 patient (#1) of 5 medical records reviewed.

The findings included:

Review of facility policy "Detection of Abuse, Abandonment, Neglect, or Exploitation," last revised 2/12/16, revealed "...Tennova Healthcare strives to the best of its ability to prohibit and protect patients from real or perceived abuse, neglect...recognizes the patient's rights to be free from mental, physical, sexual, and verbal abuse, neglect, or exploitation..." Further review revealed "...definitions: emotional abuse: willful infliction of anguish, pain, or distress through verbal or non-verbal acts...this includes, but is not limited to, isolating or frightening an adult...intentional neglect: failure to meet the needs of the dependent elderly person...this includes, but is not limited to willfully withholding food or medication...abandonment: desertion of a vulnerable individual by anyone who has assumed care or custody of that person..." Further review revealed "...if the alleged abuse is a staff member...the employee should be sent home without pay pending the administrative investigation...information will be gathered from all employees with knowledge and/or observations regarding the alleged incident...department manager will review the incident in a timely manner...Human Resources and Risk Management will be consulted regarding the need to report the alleged incident to appropriate agencies...if alleged violation is verified, appropriate action will be taken which may include...dismissal of staff member...informing state licensure agencies..."

Review of facility policy "Detection of Abuse, Abandonment, Neglect, or Exploitation," last revised 2/12/16, revealed "...employees will receive training on the following at the time of orientation and annually thereafter: abuse and neglect...related reporting requirements...prevention of abuse...detection of abuse..."

Review of facility policy "Patient Rights and Responsibilities," revised on 8/9/16, revealed "...Tennova places emphasis on the importance of respecting each patient's personal dignity, while providing considerate, respectful, and ethical care focused upon the patient's individual needs..."

Review of a facility document dated 6/21/17 revealed "...patient was brought to the ED via EMS. Patient was noted to be anxious and distressed. Patient medicated with Geodon and was placed into the vestibule of the EMS bay on a monitor...Pt. stretcher was noted to have a sign that read 'NPO [nothing by mouth]-please do not disturb-if you have questions, comments or concerns please see the charge nurse-thank you'..." Further review revealed "...pt. had no orders for NPO and visitors had been observed taking pictures of the sign..." Continued review of a written statement written by Registered Nurse (RN) (Charge Nurse/alleged perpetrator) revealed "...upon arrival [named patient] was screaming constantly for no obvious reason...was extremely loud and frightening to several patients and visitors...placed patient in an area with sliding glass doors...when [named patient] was more in control of himself he was placed directly in front of the charge nurse station...I realize my poor judgement in this particular incident. This was a mistake...I understand how the placement of the [named patient] could be viewed as negligent..."

Medical record review revealed Patient #1 was admitted on 6/18/17 at 1:18 PM with a diagnosis of Alcohol Intoxication and a history of chronic bilateral Subdural Hematoma's. Further review revealed the patient was discharged home from the ED on 6/18/17 at 10:20 PM.

Medical record review of an ED Nurses Note dated 6/18/17 at 1:21 PM revealed the patient arrived to the ED by ambulance. Further review revealed "...EMS [emergency medical services] states that patient was trying to run into traffic today and the KPD [Knoxville Police Department] had called EMS to transport patient to hospital for further evaluation. Transition of care: patient was not received from another setting of care..." Further review revealed the patient was triaged as an ESI [emergency severity index] Level 4 indicating the patient was non-emergent. Continued review revealed "...appears distressed. Behavior is anxious...denies pain..."

Medical record review of an ED Physicians Note dated 6/18/17 at 1:46 PM revealed "...presents to the ED via EMS ground with complaints of ETOH [alcohol] abuse. Erratic behavior prior to arrival tried to run into traffic the police called EMS to transport patient...was here earlier in the week on the 17th for similar complaints and has long standing history of chronic alcoholism with presentations for intoxicated behavior. He has strong odor of mouthwash denies drinking mouthwash screams loudly, he is unable to offer any particular chief complaint sitting up on the examining stretcher..." Further review revealed "...unable to obtain ROS [review of systems] due to altered mental status...vital signs reviewed...clinically intoxicated to the point of being out of control although not physically violent at presentation..." Continued review revealed the physician ordered the following laboratory tests: ETOH Level, Complete Blood Count (CBC), Magnesium level, and a Basic Metabolic Panel (BMP). Further review revealed the physician ordered Geodon (antipsychotic medication) to be administered intramuscular (IM).

Medical record review of the ED Medication Administration record revealed the Geodon was administered at 1:48 PM.

Medical record review of an ED Nursing Assessment dated 6/18/17 at 1:53 PM revealed "...appears malnourished. Behavior is restless, uncooperative. Pt. [patient] screaming and uncooperative...airway is patent, respiratory effort is even, unlabored..."

Medical record review of a nurse's note dated 6/18/17 at 2:03 PM revealed the patient's vital signs were: Blood Pressure (BP) 95/64 and Pulse 63.

Medical record review of an ED Nurses Note dated 6/18/17 at 2:12 PM revealed "...pain: reassessment: denies any pain at this time. Patient has not been educated on call light usage nor is the call light within patient's reach at this time as patient remains in hallway...patient awaiting diagnostics at this time...resting quietly, appears to be sleeping..."

Medical record review revealed no observations or assessments of the patient's condition were documented in the medical record from 2:12 PM until 8:17 PM (6 hours and 5 minutes).

Medical record review of an ED Medication Administration Record dated 6/18/17 at 8:17 PM revealed "...follow-up [to Geodon]...anxiety decreased..."

Review of an ED Security Camera Video recording, with a security officer, on 6/30/17 at 1:55 PM revealed the following:
* 6/18/17 1:33 PM: the patient was placed in the EMS entrance area, between 2 sets of automatic entrance doors by a nurse
* 6/18/17 1:34 PM: the nurse exited the area and left the patient unattended
* 6/18/17 1:37 PM: the ED Physician examined the patient in the EMS entrance area
* 6/18/17 2:03 PM: Nurse placed a portable cardiac monitor on the patient
* Further review of the video recording revealed several ED staff employees walked by the area where the patient was and the staff did not check on the patient or remove the patient from the EMS entrance area
* Further review of the video recording revealed the patient was taken back into the ED and placed in the hallway at approximately 4:40 PM (approximately 3 hours later).

Telephone interview with RN #1 revealed "...the patient was intoxicated and being loud...he was not combative and did not complain of thoughts of hurting himself..." Further interview revealed "...a few minutes later, [the charge nurse] got up from her chair and stated 'I can't take this anymore'...she was upset...said was going to take the patient..." Further interview revealed the charge nurse took the patient to the EMS entrance area and left the patient there for several hours with no supervision or monitoring. Further interview revealed the area is not an assigned patient care area in the ED. Continued interview revealed "...[charge nurse] gave the patient an Geodon injection...she said she had the patient on a portable monitor...there is no way you can see the patient from the nurses' station..."

Interview with RN #2 on 6/29/17 at 11:00 AM, in the ED exam room, revealed "...I heard a patient yelling...I went around the corner and saw a patient in between the EMS entrance doors and the ED entrance...this is not an area where patients are located or treated...I thought it was very odd...he was lying on a stretcher...there was a hand written sign on the stretcher that said 'NPO...do not disturb...any comments or concerns please see the charge nurse'...that is not a sign we would place on any stretcher..." Further interview revealed "...the charge nurse had also given the patient an injection of Geodon...there is no way the patient could be visibly viewed from the area he was in and at the nurses station..."

Interview with ED Physician #1 on 6/29/17 at 3:20 PM, in the ED Hallway, revealed "...I assumed care of the patient after [Physician #2] handed the patient off during shift change...I heard a patient yelling and I thought it was coming from room 15...I walked back there and saw it was not coming from room 15 then I saw a patient in the EMS entrance bay...he was on a stretcher and was between the entrance doors...he was yelling..." Further interview revealed "...I went out and saw the patient...asked [charge nurse] what was going on...she told me the patient was yelling and disturbing the other patients and there was no other place to put the patient..." Further interview confirmed the EMS entrance bay was not an assigned patient care area and the patients cannot be visibly viewed from the nurse's station..."

Telephone interview with RN #4 on 6/30/17 at 8:55 AM revealed "...the patient was on a stretcher in front of the nurses' station at shift change...he was sleeping..." Further interview revealed "...[charge nurse] talked about placing the patient in the EMS entrance area...she said the patient was being very loud and was disturbing the entire ED..." Continued interview confirmed the EMS entrance area is not an assigned area in the ED for patient care and there are no call lights in the area.

Interview with RN #5 on 6/30/17 at 9:20 AM, in the ED Exam Room, revealed "...the patient was placed in the EMS entrance bay...he arrived in the ED around 1:00 PM and the ED charge nurse placed the patient out there...this is not an assigned area in the ED for patient care...I have never seen a patient placed there..." Further interview revealed "...when he came in the ED he was triaged by another nurse and placed in a hallway stretcher...he was very intoxicated and was brought by EMS to the ED after he was found in the middle of a road..." Further interview revealed "...the charge nurse told the primary nurse that she was going to assume the patient's care...she took the patient and placed him in the EMS entrance bay and told the staff the patient was her patient...he was there from that time until about 4:30 PM..." Further interview revealed the staff member did not remove the patient from the area.

Interview with ED Physician #2 on 6/30/17 at 10:05 AM, in the ED Exam room, revealed the physician provided care to the patient on 6/18/17. Further interview revealed "...he was very intoxicated when he arrived...EMS reported the patient was found in the middle of the road and was brought to the ED for evaluation...he was yelling but was not combative but was somewhat disruptive...he wanted to get up..." Continued interview revealed "...I ordered 10 mg [milligrams] of Geodon IM [intramuscular] for the patient to help calm the patient down...I did not see the patient after that..."

Interview with the Charge Nurse on 6/30/17 at 11:30 AM, in the ED Exam room, revealed "...this patient is a frequent visitor to the ED...he usually comes in very intoxicated but is not violent..." Further interview revealed "...he was very loud and screaming...we were not able to redirect the patient...I felt he was frightening the other patients in the ED...I took the patient to the EMS entrance area and placed the patient against the wall while he was on the stretcher...I told the registration clerk which is located right beside the entrance area to let me know if the patient tried to get up...we do not normally place patients in that area...there are no call lights located in the area..." Continued interview revealed "...I made a mistake..."

Interview with the ED Nurse Manager on 6/30/17 at 1:15 PM, in the conference room, revealed "...on 6/21/17 we spoke with [charge nurse]...she said the patient was very loud and disrupting to the entire ED and she was trying to keep the patients from hearing that...she said she placed the patient in the EMS entrance area..." Further interview revealed "...I do not know how long the patient stayed out there...he was moved back to [ED hallway stretcher]..." Continued interview confirmed the EMS entrance was not a patient care area.

Interview with the Director of Nursing (DON) on 6/30/17 at 1:45 PM, in the conference room, revealed "...the ED Manager text me on 6/19/17 at 9:09 AM and told me about the signage on the patient's stretcher...I told him to do some investigation and get some information...on 6/20/17 he told me about the patient being placed in the EMS entrance bay...I told him we needed to interview [charge nurse] that day..." Further interview confirmed "...this is unacceptable practice...it is inappropriate to place that kind of signage on a patient bed..." Further interview confirmed "...the charge nurse failed to act in a professional manner and failed to respect the patient's dignity..."

Interview with the Chief Nursing Officer (CNO) on 6/30/17 at 2:00 PM, in the conference room, confirmed the actions taken by the nurse inappropriate and the patient's care was neglected.

Based on medical record review and interview, the facility failed to follow a physicians order for diagnostic testing for 1 Patient (#1) of 5 medical records reviewed.

The findings included:

Medical record review revealed Patient #1 was admitted to the Emergency Department (ED) on 6/18/17 at 1:18 PM with a diagnosis of Alcohol Intoxication. Further review revealed the patient was discharged from the ED on 6/18/17 at 10:20 PM.

Medical record review of a physician's order dated 6/18/17 at 1:43 PM revealed the following laboratory tests were ordered: ETOH Level, Complete Blood Count (CBC), Magnesium level, and Basic Metabolic Panel (BMP). Further review revealed the laboratory tests were cancelled on 6/19/17 at 4:47 PM (the day after the patient was discharged from the ED)

Interview with ED Physician #1 on 6/29/17 at 3:20 PM, in the ED Hallway, revealed "...I assumed care of the patient after [Physician #2] handed the patient off during shift change...I did review the patient's EKG [electrocardiogram] but did not see any [completed] labs on the medical record..."

Interview with ED Physician #2 on 6/30/17 at 10:05 AM, in the ED Exam room, revealed the physician provided the initial medical examination screening and ordered laboratory diagnostic testing for the patient. Further interview confirmed "...the patient's labs were cancelled the day after the patient was discharged...I do not know why they were not performed...I did not review any labs for the patient and it looks like [named ED physician] did not either..." Continued interview confirmed the laboratory tests as ordered by the physician were not completed on Patient #1.