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Based on observation, interview, and record review, the hospital failed to meet the patients' emergency needs in accordance with acceptable standards of practice as evidenced by:

1. The hospital failed to ensure the ED was organized to ensure the delivery of safe patient care. Cross reference to A1101.

2. The hospital failed to integrate with other hospital's department, services, and resources to ensure the availability for the ED. Cross reference to A1103.

3. The hospital failed to provide the emergency medical and nursing services following the hospital's P&Ps. Cross reference to A1104.

4. The hospital failed to ensure the accuracy and completion of the hospital's organization chart reflecting the current hospital practice and chain of commands. Cross reference to A1110.

5. The hospital failed to ensure the training of the ED physicians was completed. Cross reference to A1111.

6. The hospital failed to ensure the ED nursing staff possessed the knowledge and skills required to meet the anticipated needs of the ED. Cross reference to A1112.

The cumulative effects of these failures resulted in the hospital ED's inability to ensure the provision of quality and safe emergency services to the patients with potential medical emergencies.

Based on observation, interview, and record review, the hospital failed to ensure the ED was organized to ensure the delivery of safe patient care as evidenced by:

* Failure to ensure the critical life saving equipment was plugged in a safe manner and in the correct electrical outlet.

* Failure to ensure the pediatric and adult crash carts were checked daily.

* Failure to ensure there was a process for checking the expiration dates on medical supply labels (shelf-life verification for sterility), physical integrity of the stocked supplies, and storage of supplies to prevent crushing or damage to packaging, including removing medical supplies that should not be stored in the ED.

* Failure to ensure the adequate (different sizes) supply of hard restraints.

* Failure to ensure the Clean Supply Room was maintained in a safe, sanitary, and organized manner.

* Failure to ensure medications were stored properly and not stored in the Clean Supply Room.

* Failure to ensure there was a process for checking the temperatures in the Clean Supply Room where the temperature sensitive supplies were stored.

* Failure to ensure the patient care areas were not used to store non-related items such as the staff's personal training file, and unlaundered clothing for donation to the patients.

* The IV solutions were stocked in the blanket warmer.

* Two unlocked medical supplies cabinets were identified in the patient's treatment room.

* The isolation cart was not stocked with necessary supplies.

* Disposable thermometers were not available in the ED supply room.

* The Emergency Agencies Contact List was not updated as per the hospital's P&P.

* Broken cabinet door was identified in the patient's treatment room.

These failures had the potential to create substandard quality of care outcomes to the ED patients.

Findings:

1. On 11/14/22 at 1008 hours, the ED was toured with Quality 1 and ED Charge RN 2. The following was observed:

* The adult crash cart was not plugged in to the red electrical outlet/socket.

* The pediatric crash cart was observed plugged in to an extension cord and was not plugged in directly to the red electrical outlet/socket.

* Review of the pediatric crash cart/defibrillator checklist showed the daily check was not done or completed in its entirety for the following dates:

- September 1, 2, 5, and 12, 21, 25, 27, 28, and 29, 2022.

- October 20, 2022.

- November 2, 2022.

* Review of the adult crash cart/defibrillator checklist showed the daily check was not done or completed in its entirety for the following dates:

- September 6 and 21, 25, 28, and 29, 2022.

- October 15 and 20, 2022.

- November 2, 6, and 13, 2022

* Multiple plastic bins overcrowded with medical supplies, including expired medical supplies as follows:

- Pediatric/Infant Lumbar Puncture Tray.

- Multiple disposable Laryngeal Masks that had turned yellow and were dated as far back as 2012, 2014, and 2016.

* Multiple Mcgill forceps (an instrument) and a vaginal speculum (a medical instrument) were not stored in an organized manner (the SPD supplies were stored with multiple other non-SPD supplies).

When asked about the current process for checking expiry dates on medical supply labels (shelf-life verification for sterility), physical integrity of the stocked supplies, and the storage of supplies to prevent crushing or damage to packaging, ED Charge RN 2 stated the Materials Management Department was responsible for the supplies in the ED.

When asked about the SPD supplies including the process for stocking and the level of SPD supplies that should be stocked in the ED, ED Charge RN 2 did not respond.

The Quality 1 confirmed the findings.

On 11/15/22 at 1100 hours, the Manager of ED/ICU/CCU was interviewed about the medical supplies and SPD supplies stocked in the ED. The Manger of ED/ICU/CCU stated the ED nurses were responsible for the supplies in the ED, including stocking, storage, and checking for the expiration dates. The Manager of ED/ICU/CCU stated that procuring of SPD supplies occurred on an as needed basis. The Manager of ED/ICU/CCU further stated the SPD supplies were not stored in the ED.

2. On 11/14/22 at 1150 hours, an observation and interview in the ED was conducted with ED Charge RN 2.

ED Charge RN 2 was asked about the types of restraints utilized in the ED. ED Charge RN 2 stated the ED had non-behavioral (soft) restraints and behavioral ("leather" or hard) four point restraints.

Upon closer inspection of the hard restraints, ED Charge RN 2 stated the restraints were "not leather" but plastic.

When asked to demonstrate the proper use of the hard restraints, ED Charge RN 2 was observed manipulating the hard restraints and stated "How do you do this again..." and "Where do you tie..."

ED Charge RN 2 demonstrated how the hard restraint could be easily slipped off at the wrist. ED Charge RN 2 acknowledged the hard restraints were too large for a patient with a small body frame. When asked if the ED or hospital had different sizes, including smaller hard restraints, ED Charge RN 2 confirmed the ED or hospital had only one size of the hard restraint.

Quality 1 and ED Charge RN 2 confirmed the findings.

3. Review of the hospital's P&P titled Medication-Storage and Access dated October 2022 showed drugs and biologicals must not be stored in areas that are readily access by unauthorized individuals.

On 11/14/22 at 1518 hours, the ED Clean Supply Room ("Garage") was toured with Quality Manager 1, the Manager of ED/ICU/CCU, and Manager Materials Management. The following were observed not stored in a safe, sanitary and organized manner:

* In one plastic bin, multiple medical supplies including three vials of medication, including one lidocaine (a medication used to treat the irregular heart beat or relieve pain and numb the skin) vial and one Xylocaine (same as lidocaine) vial that were sealed; and one Xylocaine vial with a broken seal. These vials of medications were readily accessible to non-licensed staff.

* Multiple bags of IV fluids were stored on the wire cart and readily accessible to non-licensed staff.

* One vital signs machine that was readily available and accessible for use, was not covered with a clear plastic bag indicating it had been disinfected as per the Manager of ED/ICU/CCU.

* On one bedside table, multiple medical supplies were observed stored with used and dusty non-medical items, including the used yellow extension cord and other miscellaneous items, such as wall brackets and other cords.

* A used water dispenser.

* On a chair, one old telephone with a thick layer of dust was placed inside what appeared to be a computer printer paper drawer.

* On the floor, clear plastic bags with patient belongings.

* One "cast cutter" with a thick layer of dust at the base.

When asked if supplies stored in the ED Clean Supply Room were temperature sensitive, the Manager Material Management was observed reading the IV fluid bag manufacture's recommendations and stated the recommended storage room temperature was 25 degrees Celsius. The Manager of ED/ICU/CCU confirmed there was no process in place to monitor the temperature of the Clean Supply Room ("Garage").

The Manager of ED/ICU/CCU and Quality Manager 1 acknowledged the findings.


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4. On 11/14/22 at 1020 hours, a tour of the ED was initiated with the Manager of ED/ICU/CCU. During the tour of an inpatient's treatment room labeled "Subwaiting Area," two rows of unlocked cabinets were observed. The top row unlocked cabinet contained the ED's staff training certificate folders. The lower cabinet contained unlaundered clothing items. This cabinet was adjacent to the cabinet stocked with clean linens and patient's gowns.

When asked, the Manager of ED/ICU/CCU stated the clothing items were for donation to patients. The Manager of ED/ICU/CCU further stated these cabinets in patient's treatment room should be locked.

5. Review of the hospital's P&P titled Blanket Warmer Management: Infection Control dated October 2020 showed the following:

* Blankets will be kept at temperature range from 100 to 130 degrees F.

* Blanket warmer is not to be used for warming fluids or other patient care items.

On 11/14/22 at 1030 hours, during the tour of the ED with the Manager of ED/ICU/CCU, a blanket warmer was observed in patient's treatment room labeled "Team Triage Room." The blanket warmer was stocked with two bag/container of 1000 ml IV solution, blankets, and the patient' gowns. The blankets stocked in the warmer were cold to touch. When asked, the Manager of ED/ICU/CCU stated the Manager of ED/ICU/CCU would check and get back to the writer.

On 11/15/22 at 0930 hours, during the second tour of the ED with the Manager of ED/ICU/CCU and the Biomed Director to recheck the temperature of the blankets in the blanket warmer, the door of the blanket warmer was ajar and the blankets stocked in the warmer were barley warm to touch.

On 11/15/22 at 0930 hours, during an interview RN 2, RN 2 stated the warmer was just stocked and the staff should have made sure the door was completely closed.

6. During a tour of the treatment room labeled "Team Triage Room" with the Manager of ED/ICU/CCU on 11/14/22 at 1030 hours, two unlocked free standing storage cabinets were observed. These unlocked cabinets were stocked with medical and orthopedic supplies. When asked, the Manager of ED/ICU/CCU stated the Manager would notify engineering.

7. On 11/14/22 at 1100 hours, during a tour of the ED with the Manager of ED/ICU/CCU, an isolation cart was observed in Hallway 1. The isolation cart was not stocked with the necessary disposable medical supplies such as blood pressure cuff, stethoscope, and thermometers. The Manager of ED/ICU/CCU stated the Manager would confer with the Material Management.

8. On 11/14/22 at 1030 hours, during a tour of the ED's supply room with the Manager of ED/ICU/CCU, the disposable thermometers were not in stock.

On 11/14/22 at 1610 hours, during an interview with the Manager Material Management, the Manager Material Management stated stocking and restocking of the disposable thermometers was the responsibility of the ED nursing staff and the Material Management did not stock disposable thermometers.

On 11/14/22 at 1050 hours, during an interview with the Manager of ED/ICU/CCU, the Manager of ED/ICU/CCU stated the Manager of the ED/ICU/CCU was unaware whether stocking or restocking of the disposable thermometers was the responsibility of the nursing staff or the Material Management.

9. Review of the hospital's P&P titled Telephone Numbers, Emergency Numbers: Emergency Management dated January 2020 showed the list of telephone numbers shall be updated by the EOC (Executive Office Committee) as often as necessary, but no less than annually.

On 11/15/22 at 1045 hours, an interview and concurrent record review was conducted with the Chairman of the Emergency Preparedness Committee.

When asked, the Chairman of the Emergency Preparedness Committee stated the Emergency Agencies Contact List was updated nearly 3 years ago and it should have been updated more often to ensure the accuracy of the list.

10. On 11/14/22 at 1020 hours, a tour of the ED was conducted with the Manager of ED/ICU/CCU. During the tour of a room labeled OB/GYN Treatment Room, a cabinet to the left of the sink in the room was observed to be broken and off the railing. When asked the Manager of ED/ICU/CCU stated the Manager would notify the engineering.

On 11/15/22 at 1135 hours, the above findings were acknowledged by the Manager of ED/ICU/CCU.

Based on observation, interview, and record review, the hospital failed to integrate with other hospital's department, services, and resources to ensure the availability for the ED as evidenced by:

* Failure to ensure the Laboratory Department provided oversight of the daily QC tests for the point-of-care testing done in the ED.

* Failure to ensure there was a process for checking the expiration dates on laboratory testing supplies that were stored in the refrigerator.

* Failure to ensure there was a process for maintaining an adequate supply for the urine QC tests

* Failure to ensure the temperatures for the refrigerator that used for storing laboratory specimens and other laboratory materials were checked and documented daily.

* Failure to ensure the Infection Control Services implemented the updated visitation guidelines as per the State Public Health Officer Order of September 15, 2022.

* Failure to ensure the Suicide Risk Assessment P&P tool was not implemented without approval from the MEC and from the GB.

* Failure to ensure the RNs implemented the current hospital's P&P related to Suicide Risk Assessment consistently to ensure pediatric patients were assessed for suicide risks.

* Failure to ensure contract agreements for the radiology and laboratory offsite services, were maintained and readily available and accessible for review upon request and ensure the Master List of Contracted services was maintained and updated.

These failures created the increased risk of substandard healthcare outcomes to the patients in the hospital.

Findings:

1.a. Review of the hospital's P&P titled Daily Urine Quality Control Guidelines dated 8/11/22, was reviewed and showed in part:

- The use of QC materials is an integral part of good laboratory practice to assess the precision of methods and techniques. The two levels of control are used to allow performance monitoring within the clinical range. Urine QC tests will be run daily.

- Reagents and Quality Control: Two levels of control are performed every 24 hours and whenever a new bottle of reagent is first opened and before patient samples are tested.

- For Urinalysis Control Level 1 (QC 1) and Urinalysis Control Level 2 (QC 2), once opened and stored tightly capped, all analytes will be stable for 30 days at 2 - 25 degrees Celsius.

- Results shall be posted on the log sheet provided in the urine QC log.

On 11/14/22 at 1112 hours, a tour of the ED laboratory area where point-of-care testing was performed, was conducted with ED Charge Nurse 2 and Quality 1. The following was observed:

* On the counter, one Clinitek machine and the quality control log for September, October, and November 2022.

When asked, ED Charge Nurse 2 stated the Clinitek machine was used for urinalysis testing and the results would be available in one minute. ED Charge Nurse stated the urine QC tests should be done daily at the beginning of the shift.

Review of the quality control log showed the urine QC tests were not performed on 9/2, 9/4, 9/8, 9/10, 9/19, 9/21, 9/26, 9/28, 9/29, 9/30, 10/19, 10/20, 10/23, and 11/8/22.

Further review of the quality control log showed the following:

- On 09/04/22, the log showed "No Solution."

- On 09/10/22, the log showed "...Unable to QC...lab called."

- On 10/19/22, the log showed "No QC2 [sic] solution, lab called, per [Staff Name], they don't have solution for our machine."

- On 10/20/22, the log showed "No solution for QC-2."

When asked about the QC supply levels maintained in the ED and about the process for monitoring and ensuring the ED had an adequate supply for the urine QC tests, ED Charge Nurse 2 stated she was not sure. ED Charge Nurse 2 stated that if the ED ran out of the supply for the QC tests, the laboratory would be called to restock; if the laboratory could not restock the supply, the ED would not perform the QC tests. ED Charge Nurse 2 further stated that the urine specimen would have to be sent to the hospital's laboratory for processing and that would affect the ED throughput.

On 11/4/22 at 1112 hours, an observation of the refrigerator and concurrent review of the Refrigerator Temperature Log was conducted with ED Charge Nurse 2 and Quality 1. The following was observed in the refrigerator:

* Multiple disposable sampling swabs for "RSV and COVID PCR" with an expiration date of 4/2/22 (over seven months past the expiration date); the swabs were readily accessible and available for use.

b. Review of the Refrigerator Temperature log showed there was no documentation the temperatures were recorded on 1/12, 2/11, 2/14, 2/18 through 2/22, 2/24, 2/25, 3/7, 4/8, 4/14, 4/22, 10/22, and 11/13/2.

ED Charge Nurse 2 stated the refrigerator was also used for storing the opened urinalysis QC 1 and QC 2.

ED Charge Nurse 2 and Quality 1 acknowledged the findings.

On 11/15/22 at 0838 hours, the above findings were shared with the Director of Laboratory. The Director of Laboratory stated the laboratory department was responsible for oversight of the point-of-care laboratory services in the ED, including the daily QC of the Clinitek. The Director of Laboratory stated "Education is warranted" for the ED.

2. On 11/2/22 at 1005 hours, during the initial tour of the ED with the Director of Med Surge & Women's Center, a signage was observed posted to the right of Patient Service Rep window which showed outdated visitor guidelines related to COVID-19. The signage showed in part the State requirements for visitors in acute health care and long term care settings, including showing proof that fully vaccinated for COVID-19 and if unvaccinated or incomplete, to provide verification of negative COVID-19 results

On 11/7/22 at 1103 hours, the findings were shared with Quality Manager 1, including that the signage posted in the ED main lobby was not in alignment with the updated visitation guidelines as per the State Public Health Officer Order of September 15, 2022.

On 11/14/22 at 1325 hours, an interview was conducted with the Infection Control. When asked about the Environment of Care rounds, the Infection Control stated rounding was done twice a year in the ED; however, the Infection Control conducted rounding at least once a week if not more often.

When asked about the visitor guidelines signage posted in the ED main lobby, the Infection Control confirmed the signage had been removed from the ED main lobby 11/7/22.

The Infection Control was asked about the process specific to the ED for implementing the updated visitation guidelines as per the State Public Health Officer Order of September 15, 2022.

The Infection Control stated the hospital's P&P related to visitor guidelines had been revised and was scheduled for MEC and Governing Body review and approval. The Infection Control stated the ED had been updated during "huddles," the updates had been posted in the ED, and the information had been communicated verbally on nights and weekends by the Charge Nurse. The Infection Control further stated the "AFL" was posted in the ED breakroom; however, it had been taken down, "roughly two weeks ago."

On 11/14/22 at 1415 hours, ED Charge Nurse 3 was interviewed. ED Charge Nurse 3 stated she had worked in the ED for almost four years. When asked about the updated visitation guidelines as per the State Public Health Officer Order of September 15, 2022, ED Charge Nurse 3 stated she was not aware of the updated visitation guidelines.

On 11/14/22 at 1420 hours, RN 2 was interviewed. RN 2 stated she was not aware of the updated visitation guidelines.

3. Review of the hospital's P&P titled Suicide Risk Assessment, Reassessment and Precaution dated March 2021 showed in part:

- [Name of Hospital] shall conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease risk for suicide.

- [Name of Hospital] shall address the patient's immediate safety needs and most appropriate setting for treatment.

- The RN, as apart of the initial assessment process upon admission, shall use unit specific screening tools to screen the following patients for actual or potential suicide risk: All patients admitted to the hospital.

On 11/14/22 at 1119 hours, ED Charge Nurse 2 was interviewed and asked about the suicide risk assessment performed in the ED. ED Charge Nurse 2 stated the Triage Nurse should perform a suicide risk assessment on all patients. When asked about the age when pediatric patients should be screened for suicide risks, ED Charge Nurse 2 stated she was not sure. ED Charge Nurse 2 stated "I don't do a risk assessment on all pediatric patients."

ED Charge Nurse 2 stated if pediatric patient had a history of "anxiety," a suicide risk assessment would be performed.

On 11/15/22 at 1600 hours, an interview and concurrent review of the hospital's P&P related to Suicide Risk Assessment, Reassessment and Precaution was conducted with Quality Manager 1 and the Manager of ED/ICU/CCU.

The Manager of ED/ICU/CCU confirmed all ED patients, including pediatric patients, should be screened for suicide risks. The Manager of ED/ICU/CCU and Quality Manager 1 confirmed the current P&P for suicide risk assessment was not age specific. Quality Manager 1 provided the new, yet not approved, P&P that was age specific for review.

Review of hospital's P&P titled Columbia Suicide-Severity Rating Scale Non-Behavioral Health Settings showed in part, "All adolescent and adult patients greater than or equal to 12 year or older who present for care and services will be screened for suicide ideation and behavior using the Columbia Protocol...Screening very young children if cognitively impaired, for suicide ideation and behavior with age appropriate questions only if the chief complain/primary diagnosis is an emotional/behavioral disorder including substance abuse or if suicidal ideation, intent or behavior is observed or reported"

Quality Manger 1 stated the Columbia-Suicide Severity Rating Scale tool had been implemented in the ED. Quality Manager 1 confirmed the tool and the corresponding P&P had not been approved by the MEC and by the GB.

4. On 11 11/14/22 at 1714 hours, an interview and concurrent review of the hospital's Current Agreement List - October 20, 2022, was conducted with Quality Manger 1.

Quality Manager 1 confirmed the following:

* Hospital A did not have MRI services and the ED patients would have to be transported to Hospital K for MRI services.

* Hospital A would send the molecular diagnostic lab tests (e.g., COVID-19 PCR testing) to Laboratory Services 1 located at Hospital K.

Quality Manager 1 confirmed the Current Agreement List- October 20, 2022, did not show the following contracted services:

* The current agreement with Hospital K specific for offsite MRI services.

* The current agreement with Laboratory Services 1 for molecular diagnostic lab tests at Hospital K.

Quality Manager 1 confirmed the Current Agreement List had not been maintained and updated. In addition, the current agreements for the services were not available for review.

Based on interview and record review, the hospital failed to provide the emergency medical and nursing services following the hospital's P&Ps as evidenced by:

1. Failure to ensure an MSE was provided in a timely manner to determine whether or not an EMC existed for seven of 21 sampled patients (Patients 2, 3, 5, 6, 9, 10, and 11).

a. For Patient 2, the ED nursing staff did not triage the patient within five to 10 minutes of arrival to the ED as per the hospital's P&P. In addition, the ED physician did not complete the MSE documentation for Patient 2 in a timely manner.

b. For Patient 3, the ED nursing staff did not triage the patient within five to 10 minutes and did not assign a triage category accurately as per the hospital's P&P. In addition, there was no documented evidence to show the ED staff addressed Patient 3's pain and the ED physician or healthcare provider conducted an MSE for the patient before the patient was LWBS.

c. For Patient 5, the ED staff did not triage the patient within five to 10 minutes after arrival to the ED as per the hospital's P&P.

d. For Patient 6, the ED staff did not complete the triage assessment but assigned the triage category to the patient as Category 4 which was not accurately as per the hospital's P&P.

e. For Patient 9, the ED staff did not complete the triage assessment and MSE for the patient when the patient came to the ED with abdominal pain.

f. For Patient 10, the ED staff did not complete the triage assessment for the patient before transferring the patient to the L&D Unit.

g. For Patient 11, the ED staff did not complete the triage assessment for the patient before transferring the patient to the L&D unit.

h. The hospital failed to ensure the hospital's P&Ps related to triaging of the patients in the ED were consistently developed for the time frames for triaging the patients upon arrive to the ED and the patient's acuity levels.

2. Failure to ensure the necessary stabilizing treatment was provided within the capabilities of the hospital for nine of 21 sampled patients (Patients 1, 8, 12, 13, 14, 15, 16, 20, and 21).

a. The ED staff did not implement the hospital's P&Ps related to mental health evaluations, suicidal risk precautions, and code gray for Patient 8. The ED staff did not conducting a thorough contraband search for Patient 8; did not place the patient in a safe, closely observed area, and clear of items that could cause harm to patient or others; did not active a Code Gray when the patient's violent behavior escalated; and did not ensure additional interventions to stabilize the patient as per the hospital's P&Ps.

b. The ED staff did not implement the hospital's P&P related to high risk patient for Patients 13 and 22. The ED staff did not provide the 1:1 sitter/observer to Patients 13 and 22 when Patients 13 and 21 were on an involuntary psych hold or 5150 hold.

c. The ED staff did not assess the vital signs every two hours to Patients 12, 13, 16, 20, and 21 as per the hospital's P&P.

d. The ED staff did not ensure the pain management for Patients 12, 14, 15, and 20 as per the hospital's P&P.

e. The ED staff did not check the temperature for Patient 1 when checking the vital signs for the patient as per the hospital's P&P.

f. The ED staff did not complete the neurological assessment for Patient 1.

g. The ED staff did not ensure Patient 1's SBP was maintained between 100 and 140 mmHg for approximately one hour and 34 minutes, or on 9/5/22 from 0615 to 0749 hours as per the tele neurologist's recommendation.

3. Failure to ensure the ED staff appropriately transferred four of 21 sampled patients (Patients 1, 5, 16 and 21) from the ED to other hospitals.

a. For Patient 1, the ED staff did not implement the hospital's P&Ps related to transferring the patient to the HLOC.

* The ED physician did not contact and secure the receiving physician of Hospital B who would attend the medical needs of the patient and would accept the responsible for the patient's medical treatment and hospital care as per the hospital's P&P and the Transfer Agreement between Hospital A and Hospital B.

* The ED staff did not call 911 to transfer the patient to the HLOC or Hospital B after obtaining the destination from Hospital B and after being aware the ETA of Ambulance Company 4 was more than 30 minutes as per the hospital's P&P.

* The ED staff did not send the Ambulatory Assessment, Progress Notes, and Vital Sign reports when transferring the patient to Hospital B as per the hospital's P&P and did not ensure the Transfer Summary and Certification was signed when the patient was about to be transferred to the HLOC.

b. For Patients 5, 16, and 21, the ED staff did not complete the Transfer Summary and Certification when transferring these patients to other hospitals as per the hospital's P&P.

4. Failure to maintain the updated list of contracted services, including the contracted services specific to the ED and failure to ensure the yearly evaluation of contracted services including the ambulance services as per the hospital's P&P.

5. Failure to ensure the completion of the ED and L&D Central logs.

These failures had the potential to result in poor clinical outcomes and serious adverse event for patients receiving ED services in the hospital.

Findings:

1. Review of the hospital's P&P titled Triage dated January 2022 showed the following:

* All individuals who come to the hospital and require examination or treatment will be triaged by the ED RN within 5-10 minutes of arrival to the ED to determine priority of medical screen/care based on physical, psychological, and social needs.

* The four categories of triage include the following:

- Category 1 - Emergency

- Category 2 - Urgent

- Category 3 - Non-urgent

- Category 4 - Maternity. Pregnant women with gestational age of 20 weeks and beyond and whose complaint appears to be related to their pregnancy, will be transported to the Labor and Delivery Department for medical screening, examination, and treatment. Pregnant women with gestational age of less than or equal to 20 weeks and of greater than or equal to twenty (20) weeks whose complaint is clearly unrelated to their pregnancy, will be assigned an acuity level and evaluated and treated in the ED.

* The triage RN will evaluate and categorize each patient into either Emergent, Urgent, Non-urgent, or Maternity categories and will implement emergency intervention as needed.

* Immediately following the rapid assessment, the RN will record at a minimum the following on the ER nursing record:

- Time of Triage

- Chief Complaint

- Limited Subjective/Objective Data

- Pain Assessment

- Classification or Category

* Documentation on first page of Emergency Room Flow Sheet includes the LMP is applicable, objective including nursing observation, vital signs, and classification.

Review of the hospital's P&P titled EMTALA: Emergency Medical Screening Examinations, Treatment and Transfers dated 8/2020, showed all women who are pregnant with a gestational age of twenty (20) weeks and beyond, who present to the ED with a complaint which is clearly unrelated to their pregnancy, will receive a medical screening examination the ED Physician, and where appropriate, will be sent to the Labor and Delivery area for monitoring.

Review of the hospital's P&P titled Triage of OB Patient dated 9/2020, showed all maternity patients who present to the ED for care, will be triaged by the RN. For the patient who is over 20 weeks gestation, the ED triage nurse is to complete the triage section of OB Triage form; and based on this assessment, it will be determined if the patient will be transported immediately to the L&D unit or stay in the ED for exam and treatment. For patient who is with less than 20 weeks gestation, the ED triage nurse will do initial screening and patient will be seen as ED patient.

a. On 11/2/22 at 1528 hours, an interview and concurrent review of Patient 2's medical record was conducted with Quality Manager 1.

Patient 2's medical record showed Patient 2 presented to the ED on 11/1/22 at 2243 hours and left AMA on 11/2/22 at 0435 hours.

Review of the Triage Report showed Patient 2 was triaged on 11/1/22 at 2309 hours, or 26 minutes after arrival to the ED which was not consistent with the hospital's P&P.

Further review of Patient 2's medical record showed the medications were ordered for nausea and vomiting on 11/1/22 at 2346 hours, and laboratory testing was done on 11/2/22 at 0100 hours. However, there was no MSE documentation found in the record.

Quality Manager 1 acknowledge the findings. Quality Manager 1 confirmed there was no MSE documentation in the record (approximately 17 hours and 45 minutes after Patient 2 presented to the ED). When asked how soon the physician should have documented the MSE, Quality Manager 1 stated she could not recall the time frame; Quality Manger 1 stated approximately 14 days but was not sure. Quality Manager 1 stated it would be best to interview the Director of Medical Staff to confirm how soon the ED physician should document the MSE.

On 11/2/22 at 1558 hours, the Director of Medical Staff was interviewed and was asked how soon the ED physician should document the MSE. The Director of Medical Staff stated the MSE should be documented in "real-time."

b. On 11/3/22 at 1345 hours, an interview and concurrent review of Patient 3's medical record was conducted with the Manager of ED/ICU/CCU. Patient 3 presented to the ED on 10/4/22 at 0530 hours with a headache and the pain level of nine out of 10 (on the pain scale from zero to 10, zero indicates the patient has no pain; and 10 indicates the patient has severe pain).

* Review of the triage report showed Patient 3 was triaged on 10/4/22 at 0604 hours, or 34 minutes after arrival to the ED which was not consistent with the hospital's P&P.

* Patient 3's acuity level was documented as Category 4 which was not consistent with the hospital's P&P titled Triage as the hospital's P&P showed Triage Category 4 was designated for the maternity patients.

* Review of the Ambulatory Assessment/History Report showed Patient 3's pain level was 9 out of 10 on 10/4/22 at 0604 hours. There was no documented evidence showing the ED staff had addressed the patient's pain. There was no documented evidence showing the ED nursing staff had communicated with the physician about the patient's pain level. In addition, there was no MSE documentation in the record.

Review of the Central Log showed Patient 3 was LWBS on 10/4/22 at 0711 hours, or approximately 1 hours and 40 minutes after arrival to the ED.

The Manager of ED/ICU/CCU acknowledged the findings.

c. On 11/7/22 at 1628 hours, an interview and concurrent review of Patient 5's medical record and concurrent interview was conducted with the Manager of ED/ICU/CCU.

Patient 5's medical record showed Patient 5 presented to the ED on 10/31/22 at 1236 hours, with midsternal chest pain.

Review of the Triage Report dated 10/31/22, showed Patient 5 was triaged on 10/31/22 at 1258 hours, or 22 minutes after arrival to the ED.

Review of the Emergency Department Record dated 10/31/22 at 1257 hours, showed the ED provider contacted or screened Patient 5 on 10/31/22 at 1255 hours, or 19 minutes after arrival to the ED.

Patient 5 was not triaged within five to 10 minutes after arrival to the ED as per the hospital's P&P.

The Manager of ED/ICU/CCU acknowledged the findings.

d. On 11/2/22 at 1606 hours, an interview and concurrent review of Patient 6's medical record was conducted with Quality Manager 1.

Patient 6's medical record showed the patient presented to the ED on 11/1/22 at 2010 hours.

Review of the Triage Report showed the following:

* Patient 6 was triaged on 11/1/22 at 2020 hours. The patient's chief complaint was "MVC-Car: pain in limbs." The sections of "Pregnant?" and "LMP" were left blank.

* Patient 6 was in the bathroom on 11/1/22 from 2020 hours through 2040 hours. At 2040 hours, Patient 6 exited "lobby following coming out of lobby bathroom."

There was no documentation of the patient's pain level or vital signs. There was no documentation of limited subjective data including appearance or behavior. There was no documentation to show further action was taken when the patient was seen leaving the ED lobby.

Further review of the Triage Report showed the patient's acuity level was "4" which was not consistent with the hospital's P&P titled Triage as the hospital's P&P showed Triage category 4 would be designated for the maternity patient.

Quality Manager 1 acknowledged the findings.

e. On 11/4/22 at 1328 hours, an interview and concurrent review of Patient 9's medical record was conducted with the Manager of ED/ICU/CCU.

Patient 9's medical record showed the patient presented to the ED on 6/25/22 at 2120 hours, for abdominal pain.

Review of the Triage Report showed Patient 9 arrived to the ED on 6/25/21 at 2120 hours, and was triaged on 6/25/22 at 2137 hours. The patient's chief complaint was abdominal pain. The patient was brought into the ED with the altered level of consciousness. At 2130 hours, the patient's blood sugar level was 36 mg/dL (a critical low level of blood sugar) and the patient was immediately given D50 (Dextrose 50, a medication used to treat low blood sugar). The patient's BP was 184/84 mmHg. The sections of "Pregnant?" and "LMP" were left blank. There was no documentation showing the nursing staff checked the patient's temperature. There was no documentation showing the nursing staff assessed the patient's pain level. Further review of the Triage Report showed Patient 9's acuity level was "2."

There was no MSE documentation by the ED physician. There was no documented evidence to show the physician's order was obtained to administer the D50 to the patient.

Further review of Patient 9's medical record showed Patient 9 was transferred to the Labor and Delivery Unit on 6/25/22 at 2141 hours.

Review of the L&D documentation dated 6/25/22 at 2145 hours, showed Patient 9 was 28 weeks pregnant and the patient's BP was 114/59 mmHg.

The Manager of ED/ICU/CCU acknowledged the findings. The Manager of ED/ICU/CCU stated there was no MSE documentation by the ED physician and there was no documentation of the patient's LMP, GA, or that the patient was pregnant. The Manager of ED/ICU/CCU stated it was not clear on the triage documentation why the patient had been transferred to the L&D Unit on 6/25/22 at 2141 hours.

f. On 11/4/22 at 1357 hours, an interview and concurrent review of Patient 10's medical record was conducted with the Manager of ED/ICU/CCU and Quality Manager 1.

Patient 10's medical record showed the patient presented to the ED on 7/9/22 at 0313 hours.

Review of the ED Summary Report dated 7/9/22, showed the patient's chief complaint was "pregnancy issues < (less than) 20 wk (weeks)." There was no documentation showing the triage category or ESI level.

The Manager of ED/ICU/CCU confirmed there no was documented evidence showing the ED staff completed the triage assessment for the patient. There was no documentation showing the patient's LMP, GA, and pain level. There was no documentation in the ED Summary Report showing the patient was transferred to the L&D unit.

Review of the L&D documentation dated 7/9/22 at 0436 hours, showed Patient 10 had the Estimated Gestational Age of 37 weeks and 5 days. Patient 10's reason for visiting was abdominal pain that started at midnight.

The Manager of ED/ICU/CCU acknowledged the findings.

g. On 11/4/22 at 1420 hours, an interview and concurrent review of Patient 11's medical record was conducted with the Manager of ED/ICU/CCU.

Patient 11's medical record showed Patient 11 presented to the ED on 8/23/22 at 0156 hours, with abdominal pain.

There was no triage documentation. There was no documentation showing the ESI level. There was no documentation showing the patient was pregnant. There was no documentation showing the patient's LMP, GA, or the pain level. There was no documentation in the ED Summary report showing the patient was transferred to the L&D unit.

Review of the L&D documentation dated 8/23/22 at 0215 hours, showed Patient 11's gestation was 40 weeks and 5 days.

The Manager of ED/ICU/CCU acknowledged the findings.

h. On 11/7/22 at 1401 hours, an interview and concurrent review of the hospital's P&Ps related to triaging, ESI levels, and inconsistency was conducted with the Manager of ED/ICU/CCU.

Review of the hospital's P&P titled Assessment of Emergency Department Patient (Adult and Pediatric) dated September 2020 showed a walk- in patients will be triaged by ER RN within 30 minutes of arrival to the ED and the patients arriving by ambulance will be triaged by ER RN upon arrival to determine triage level.

Review of the hospital's P&P titled EMTALA: Emergency Medical Screening Examinations, Treatment and Transfers dated August 2020 showed triage means the priority given to an individual or individuals for diagnostic and therapeutic interventions in the ED.

* There are five triage levels used by the ED staff as follows:

- Level 1 or Resuscitation

- Level 2 or Emergent

- Level 3 or Urgent

- Level 4 or Semi Urgent

- Level 5 or Non-Urgent

The Manager of ED/ICU/CCU was questioned about the P&Ps related to triaging and ESI levels and the inconsistencies. The Manager of ED/ICU/CCU confirmed the P&Ps related to Triage and ESI levels were conflicting, including the time frames for triaging the patients upon arrival to the ED and the ESI levels. The Manager of ED/ICU/CCU confirmed the time frame for triaging patient upon arrival to the ED was not consistent for the hospital's P&Ps titled Triage and Assessment of Emergency Department Patient (Adult and Pediatric). The Manager of ED/ICU/CCU stated one hospital P&P indicated patients should be triaged within 5-10 minutes upon arrival to the ED and the other P&P indicated patients should be triaged within 30 minutes. The Manager of ED/ICU/CCU stated one P&P indicated there were four ESI levels and the other P&P indicated there were five ESI levels.

2 a. Review of the hospital's P&P titled Mental Health Evaluations in the Emergency Department dated September 2020 showed in part:

* The hospital will provide assessment, care and referral for patients who suffer from psychiatric disturbances and/or symptoms of substance abuse.

* The Procedure section showed the following:

- All patients needing placement in behavioral health setting will be placed in a safe, closely observed area, clear of items that can cause harm, effective care, treatment and services.

- For Suicidal Patients: Patients who have attempted suicide or demonstrated suicidal tendencies will be evaluated by P.E.T evaluator prior to discharge. The suicide precautions are initiated by removing belts, ties, and sharps from area; keeping patient under constant observation; and contacting the House Supervisor/staffing office if additional staff needed. If a patient attempts to leave hospital or elope, contact Security and if necessary, [Name of Police Department], and notify physician. If the patient becomes assaultive, call code Gray and/or restrain the patient if the patient is danger to self and others and notify physician.

Review of the hospital's P&P titled Suicide Risk Assessment, Reassessment and Precautions dated 3/2021, showed when a patient is identified at risk for suicide, the staff shall:

* Place patient on "Suicide Precaution" immediately and notify the Department Manager/designee and the attending physician.

* Thoroughly examine the environment prior to placing the patient at risk for suicide in any room and/or treatment area to ensure that patients do not have to access to items that could be harmful (sharp objects, plastic bags, cleaning solvents, etc.).

* Perform contraband search of his/her belonging in order to remove any items that could be harmful (sharp objects, alcohol, drugs, rope, plastic bags, etc.) out of patient's reach.

* Monitor patient continuously and keep close physical proximity to the patient at all times.

* Suicidal patients will be on 1:1 observation. The Sitter/Observer will remain within 6 feet of patient and maintain constant visual contact with the patient at all times.

* Notify the physician if the patient threatens elopement. If the patient elopes, immediately notify the physician, security, House Supervisor, and [local] Police Department, call the patient's home/family, and initiate a Code Green in case the patient is still within the hospital.

* Patients will not be discharged while on suicide precautions unless they are transferred to an appropriate receiving facility for further care.

* Employees shall follow unit specific policies and document the screening/assessment, reassessment, monitoring, patient/family education, safety contracts, care and treatment plan of the suicidal patients; and use the Close Observation Form to document every 15 minutes checks during suicide precautions.

Review of the hospital's P&P titled Code Gray dated 1/2020, showed the following:

* The hospital will provide a safe and secure environment for patients, visitors, and staff. When staff are concerned about their own safety and the safety of others due to abusive or assaultive behavior of a patient, visitor, or staff, they are to initiate a CODE GRAY.

* There is a Code Gray team assigned every shift. This team responds to Code Gray calls. The team is comprised of staff Golden Years, Emergency Department, and Security Staff. Facilities Staff and Administrative Supervisor may also respond.

* Staff will respond to the page for Code Gray to help unit staff manage or de-escalate the situation by a show of force, to gain cooperation of the abusive or assaultive person, or to subdue and restrain the individual if necessary.

* If necessary, [Name of Policy Department] will be called to assist with combative individual.

On 11/3/22 at 1540 hours, an interview and concurrent review of Patient 8's medical record was conducted with the Manager of ED/ICU/CCU.

Patient 8's medical record showed the patient came to the ED on 11/1/22.

Review of the Triage Report dated 11/1/22, showed Patient 8 was brought in by ambulance on 11/1/22 at 0224 hours, from a sober living facility with the chief complaint of suicidal ideation. As per the EMS, the patient "Used a kitchen knife to harm-self 20 minutes PTA (prior to arrival)." The patient had a laceration to the left forearm. The patient was triaged at 0241 hours.

Review of the Emergency Department Record electronically signed by Physician 1 on 11/1/22 at 0644 hours, showed the following:

* The History Of Present Illness section showed Patient 8's chief complaint was suicidal gesture. The patient admitted that he was not himself, but denied he wanted to harm anybody else.

* The Symptom Description section showed Patient 8 had depression for one to two days. The intensity of symptoms was mild. There was no alleviating factor reported. The exacerbating factors included "Broke up with girlfriend."

* The Physical Exam Narrative section showed the patient's mood appeared depressed.

* The Results section showed the urine drug screen was positive for THC.

* The Progress section showed Patient 8's condition was stable at 0545 hours. The plan included the patient was medically cleared for psychiatric evaluation.

* The ED Course/Medical Decision-Making section showed the following:

- At 0252 hours, the patient was assessed by Physician 1.

- Medical clearance was initiated.

- Based on history of present illness, physical exam, and ED evaluation, the patient would be medically cleared for psychiatric evaluation.

* The Disposition section showed:

- The disposition time was 0554 hours

- The diagnosis were suicidal gesture, suicidal ideation, and superficial forearm lacerations.

- The patient's condition was stable.

- The discharge section showed "pending psychiatric evaluation."

Review of the Blank ED Progress Note electronically signed by the Medical Director of ED on 11/1/22 at 1829 hours, showed the patient care was transferred to the Medical Director of ED on 11/1/22 at 0700 hours. At 1100 hours, the P.E.T. team came to evaluate Patient 8 and placed the patient on a 5150 for being a danger to self. The patient was diagnosed with depression NOS.

Review of the Application for up to 72-Hour Assessment Evaluation, And Crisis Intervention or Placement for Evaluation and Treatment signed by RN 4 on 11/1/22 at 1000 hours, showed the following:

* The RN was called to [Name of Hospital] ER to evaluate Patient 8 who was from sober living after found by staff cutting his forearm with a kitchen knife.

* Upon interview, the patient was guarded, had poor eye contact, withdrew to self, and soft spoken. The patient admitted to cutting himself as a suicidal attempt but would not disclose further. The patient was unable to formulate a viable safety plan. Patient lacked positive coping skills, had poor impulse control, and remained unpredictable.

* The patient reported a long psychiatric history of multiple hospitalization, the last over a year ago. The patient stated he had attempted suicide by cutting a few times in the past. The patient reported he was currently taking Seroquel (an antipsychotic), an antidepressant, and something for anxiety. The patient was currently at a sober living [Name of Facility]. The patient stated he was followed by a therapist and a psychiatrist there.

* Based upon the above information, there was a probable cause to believe that said person was, as a result of mental health disorder as Danger to Self (DTS).

Review of the [Name of Mental Health Facility] Crisis Response Team Evaluation dated 11/1/22, showed the assessment was completed at 1030 hours. Further review showed the following:

* The Areas of Impairment section showed the boxes of Suicidal Behavior, Suicidal Thought, and Dysphoric Mood were checked.

* The Mental Status section showed the patient's appearance was appropriate. The patient was soft spoken. The patient was depressed. The patient had poor insight and poor judgment. The patient was oriented to person, place, purpose, and time. The box of "thought blocking" was checked.

* The Legal Status Following Evaluation section showed the boxes of "Meet 5150 Criteria as:" and "Danger to Self: were checked. The patient's legal status was "5150" and the patient had no conservatorship.

* The Interventions/Recommendations section showed to refer to Inpatient Receiving Facility as To Be Determined

A subsequent review of the Blank Progress Notes electronically signed by the Medical Director of ED on 11/1/22 at 1839 hours, showed the following:

* At 1530 hours, Patient 8 came to the nursing station and stated he was no longer suicidal. The patient requested his telephone and the rest of his belonging. The patient was told he could not receive his belonging because he was on a 5150 hold. The patient had a vaping device in his possession and began to vape in the hallway in the ED. The patient stated again that he was not suicidal and desired to leave. He states that the PET team representative evaluated him when he was sleeping and that it was not an appropriate evaluation.

* At 1706 hours, the police arrived at the ED and stated that they could not force the patient to stay in the safety watch room.

* At 1730 hours, the news that the patient should stay was a 5150 as he was determined to be a danger to self. Patient stated that he was not a danger to himself, was not suicidal. The patient stated that this was not a present and he did not desire to hurt himself or anyone else. He then proceeded to throw the EKG machine on the ground, the vital signs machine on the ground, dumped his food, and dumped several trash cans.

* The physician's impression was that "the patient is alert and orientated x3, conversant, and does not desire to stay in hospital. He stated that he cut himself on his left forearm because he wanted to relieve stress, but he stated he was no suicidal. It is my impression that the patient has had a previous episode of this type, he does not desire to stay in the hospital. It is my impression that the patient did not desire to stay in the hospital, and escalated the behavior to leave the hospital, the patient decide to disrupt the patient flow, and attempted to damage equipment because he was not obtaining is desired result. I do not believe that his behavior was calculated and measured."

* "[Name of Mental Health Hospital] PET team was called to reevaluate the patient, they stated that they could not reverse a 5150 hold."

* The patient was given his belonging, the patient elected to elope.

* The Disposition section showed the disposition as "Transfer."

Review of the Progress Notes Report from 11/1/22 at 0224 hours to 11/5/22 at 0212 hours, showed the following:

* On 11/1/22 at 0550 hours, "Patient's belonging placed in locked room with patient labels placed on bag."

* On 11/1/22 at 0700 hours, the patient had a sitter at the bedside for 1:1 monitoring.

* On 11/1/22 at 1158 hours, the patient was on suicide precautions.

* On 11/1/22 1407 hours, Hospital H called to update the ED that Hospital H did not have beds available.

* On 11/1/22 at 1530 hours, "Patient seen walking standing in front of nurses station. Refused to return to his room." The patient stated "I want my stuff. I need to leave." The patient refused to listen to explanation by multiple staff members, including the Medical Director of ED, nurses, and Manager of ED/ICU/CCU regarding the 5150 status or "72 hour psych hold." The patient continued to walk around the nurse's station repeating the same statement for 50 minutes. The Medical Director of ED was aware. At 1620 hours, the patient walked out the ED door. The Police Department was notified to come to the ED by the Manager of ED/ICU/CCU.

* On 11/1/22 at 1637 hours, "Patient seen using vape in hospital hallway. Instructed to stop and hand over vape device. Patient is non compliant. (the name of the Medical Director of ED) aware. Awaiting further orders. MD declines to give order for Geodone (an antipsychotic) at this time. Awaiting Police Department."

* On 11/1/22 at 1740 hours, "Patient see violently destroying property. Pt (patient) throwing fire extinguisher, isolation cart, IV pump, EKG machine to the floor. Pt difficult to re-direct. Patient stepped out of ER doors at 1750 and left hospital premises with steady gait. Police Department notified."

* On 11/1/22 at 1800 hours, "Officers here. Informed them that the patient eloped."

On 11/3/22 at 1540 hours, during an interview and concurrent review of Patient 8's medical record with Manager of ED/ICU/CCU. The Manager of ED/ICU/CCU stated Patient 8 had been evaluated by the P.E.T clinician and was placed on a 5150 hold. The Manager of ED/ICU/CCU stated she was present in the ED and witnessed the patient "Getting more aggressive...very agitated." He positioned himself in front of the nursing station and became disruptive and violent, including throwing medical equipment around the ED. The Manager of ED/ICU/CCU stated the patient was "non cooperative." In addition, the patient was intimidating as he was "tall." The Manager of ED/ICU/CCU confirmed the RNs, Charge Nurse, and Manager of ED/ICU/CCU had recommended to the Medical Director of ED "other intervention" including medicating the patient; however, the Medical Director of ED did not order medications or other interventions to subdue the patient. The Manager of ED/ICU/CCU confirmed the patient was given back his belonging and the patient left the ED. When asked if the patient had indeed "eloped" or if the patient was allowed to leave the ED, the Manager of ED/ICU/CCU did not respond. The Manager of ED/ICU/CCU confirmed Patient 8's medical record did not show documentation the patient had any subsequent visits to the ED after the patient "eloped" on 11/1/22.

On 11/7/22 at 1523 hours, an interview and concurrent review of Patient 8's medical record was conducted with Quality Manager 1. The following findings were shared and acknowledged by Quality Manager 1.

* The ED staff did not implement suicide precautions, including conducting a thorough contraband search for Patient 8. The patient was in his possession a vaping device and the patient's belonging were returned to the patient.

* The ED staff

Based on interview and record review, the hospital failed to ensure the accuracy and completion of the hospital's organization chart reflecting the current hospital practice and chain of commands. This failure had the potential to result in poor clinical outcomes and serious adverse events for the patients receiving ED services in the hospital.

Findings:

On 11/2/22 at 1116 hours, an interview was conducted with the HS. The HS was asked about the roles of the HS in the ED. The HS stated the HS was receiving the calls related to staffing and patient issues that could not be resolved at the clinical sites. The HS stated the HS position was higher than the Charge Nurse position; the HS would reach out the department Director, CNO, or CEO if needed. The HS stated the HS was a part of the hospital's Chain of Commands.

On 11/3/22, review of Patient 1's medical record showed ED Charge RN 1 documented on the Progress Notes Report that on 9/5/22 at 0059 hours, a Hospital Supervisor told ED Charge RN 1 that the interim CNO permitted the RN to transfer the patient to other hospital.

On 11/4/22 at 1033 hours, the CEO was asked about the reporting process when the hospital staff had any issue with the patient care, the CEO stated the hospital staff should follow hospital's chain of commands to report the issues.

On 11/14/22 at 1110 hours, an interview and concurrent review of the hospital's document was conducted with the CQO and Quality Manager 1. The CQO presented the copy of Hospital A's Organization Chart dated 11/14/22. Review of the Hospital A's Organization Chart showed there was no the HS position listed in the hospital's Organization Chart. Quality Manager 1 provided the Chain of Command Algorithm 2022 which there was no the HS position listed on the algorithm. Quality Manager 1 and the CQO stated the HS position should be added to be next level of the CNO and would be parallel with the unit directors. The CQO stated the hospital's Organization Chart was inexact.

Based on interview and record review, the hospital failed to ensure the training of the ED physicians was completed as evidenced by:

1. There was no documented evidence showing the continuing medical education pertinent to the ED specialty for two ED physicians (ED MDs 1 &2).

2. The EMTALA training was not provided to the ED physicians to ensure compliance with federal laws regarding the emergency transfers.

These failures had the potential to result in poor clinical outcomes and serious adverse event for patients receiving ED services in the hospital.

Findings:

1. Review of the hospital's Medical Staff Bylaws, Rules and Regulation showed the applicants shall have the burden of producing adequate information for a proper evaluation of his/her competency. The information shall include the continuing medical education for the past two years. The Medical Executive Committee should make recommendations to the GB on their qualifications to the provide those services and on the degree of supervision required.

The Credential Committee shall review and evaluate the qualifications of the allied health professionals to provide specific patient care services in the hospital and the minimum standards of education eligible to apply for the opportunity to perform in-hospital services.

Review of the Department of Medicine - Delineation of Clinical Privileges - Emergency Medicine showed the physicians may apply or reapply for privileges for which they can demonstrate training, experience, and current clinical competencies. It shall include the documentation of required continuing medical education pertinent to the applicant's medical specialty.

On 11/4/22 at 1150 hours, the credential files of ED MD 1 and ED MD 2 were reviewed with the Director of Medical Staff. The Director of Medical Staff confirmed the hospital did not provide the EMTALA training for the medical staff and the ED providers were not required to have the EMTALA training. When asked, the Director of Medical staff confirmed there was no document showing these two physicians had their continuing medical education pertinent to the emergency service. The Director of Medical Staff confirmed the findings.


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2. Review of the hospital's P&P titled EMTALA: Emergency Medical Screening Examination, Treatment and Transfers dated August 2020 showed it is the policy of the hospital to provide a medical screening examination by a qualified medical person to any individual who comes to the hospital and a request is made by an individual who is not a patient or on behalf of the individual for medical treatment (whether or not eligible for insurance benefits and regardless of ability to pay) to determine if the individual has an emergency medical condition; and if it determined that the individual has an emergency medical condition, to provide the individual within the capabilities of the hospital, or to arrange for transfer of the individual to another medical facility in accordance with the procedures set forth below. The ED physician is responsible for evaluating, ordering and arranging for all transfers or referrals of patients from the ED to other facilities for immediate care. The hospital's medical staff members and employee will be provided with the copy of this guidelines and advised the hospital is required to comply with the federal and state laws regarding the emergency transfer.

On 11/4/22 at 1126 hours, an interview was conducted with Quality Manager 1. Quality Manager 1 was asked if the ED physicians had received training of EMTALA to ensure compliance with federal laws specifically for emergency transfers.

On 11/4/22 at 1128 hours, the Director of Medical Staff was interviewed and confirmed the ED physicians had not received training of EMTALA. The Director of Medical Staff stated EMTALA training was not required for the ED physician.

Based on observation, interview, and record review, the hospital failed to ensure the ED nursing staff possessed the knowledge and skills required to meet the anticipated needs of the ED as evidenced by:

* Failure to ensure the Manger of ED/ICU/CCU's employee file was maintained and updated. The Manger of ED/ICU/CCU's Job Description upon hire was in April 2022. The Manager of ED/ICU/CCU have not maintained the RN competencies including PALS.

* Failure to ensure the hospital had consistent job descriptions for the Manager of ED/ICU/CCU and for the ED RNs.

* Failure to ensure the ED RNs were competent in the MH management and failure to ensure the hospital had a process in place for the MH management, specific to the ED.

These failures placed the ED patients in an emergency situation at the potential risk of harm or death.

Findings:

1. On 11/15/22 at 1000 hours, an interview and concurrent review of the personnel file for the Manager of ED/ICU/CCU was conducted with the HR Manager.

a. The HR Manager confirmed the Manager of ED/ICU/CCU's personnel file was not maintained and updated, including the signed Job Description upon hire (4/2022) for the Manager of ED/ICU/CCU. The HR Manager stated the official title for the Manager of ED/ICU/CCU was the "Clinical Director."

b. The HR Manager confirmed the Manager of ED/ICU/CCU or "Clinical Director" had not maintained the RN competencies including PALS. The HR Manager stated it was not required for the position of Clinical Director.

c. Further review of the "Clinical Director" Job Description showed the following:

- Department: ER and ICU

- Reports to: Director of Nursing

- Duties and Responsibilities: conduct Childbirth Preparation Classes, prepare for all off- site Maternity Orientation Events and other community outreach events, follow through monthly with distribution of completed materials as appropriate...

The findings were shared with the HR Manager. The HR Manager confirmed that the Duties and Responsibilities in Job Description were incorrect.

d. Review of the Job Description for the ED RN was conducted with the HR Manager.

The HR Manager confirmed the hospital had two different job descriptions for ED RNs. One RN job description showed PALS was a requirement and the other RN job description showed PALS was not a requirement.

On 11/15/22 at 1452 hours, the CNO was interviewed. The findings were shared with the CNO. The CNO stated the "Clinical Director" reported to the CNO and not to the DON as indicated on the job description. In addition, the CNO stated there was the potential for the "Clinical Director" to work in the unit taking on the role of the Charge Nurse. The CNO acknowledged the "Clinical Director" would be required to maintain the ED RN competencies, including PALS certification. The CNO acknowledged the inconsistencies with the job descriptions.

2. On 11/14/22 at 1119 hours, ED Charge Nurse 2 was interviewed about Malignant Hypothermia. ED Charge Nurse 2 confirmed the medication succinylcholine (a muscle relaxant) was administered in the ED.

When asked, ED Charge Nurse 2 could not verbalize the potential adverse reaction to succinylcholine or describe the MH condition. ED Charge Nurse 2 stated the MH cart was not maintained in the ED; it was located in the OR hallway; if the MH cart was required, the House Supervisor had the key to open the OR after hours.

On 11/15/22 at 1340 hours, RN 4 was interviewed and stated she was a newly graduated nurse and started working in the ED on July 2022. When asked about the MH, RN 4 stated "I don't know too too much about it." When asked if she had received training, RN 4 stated "I'm sure." When asked the location of the MH cart, RN 4 stated she was not sure. RN 4 was observed turning over her ID badge and stated an MH Code could be activated.

On 11/15/22 at 1510 hours, Quality Manger 1 confirmed the hospital did not have the P&P for activating an MH Code. Quality Manger 1 stated the information on the back of the ID badge was not correct. In addition, the Quality Manger 1 confirmed the hospital did not have the P&P for MH specific to the ED.