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Based on observation, interview and record review, the hospital did not protect the patient's rights by failing to:

1. Notify a responsible party of the minor patient's admission to the hospital - See A 133.

2. Provide visual and auditory patient privacy in the ED for all the patients being triaged in Room 6. Protected health information (PHI) was visible and audible to other patients and visitors when the nursing staff obtained it from the patients - See A 143.

3. Provide a safe setting. Medical supplies including needles and syringes were found accessible to patients, visitors and unlicensed staff in unlocked cabinets - See A 144.

4. Take measures to protect patients from abuse/harassment after a formal patient complaint/allegation regarding sexual harassment - See A 145.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on interview and record review, the hospital failed to notify a responsible party of the minor (age seventeen or under) patient's admission to the hospital for one of 54 sampled patients (Patient 35). This could potentially result in difficulty for the responsible party to locate the patient and provide support, advocacy and information to assist in the patient's plan of care.

Findings:

On 5/17/10, review of the hospital's discharge policy and procedure titled Department of Emergency Medicine: Nursing Services Unit Structure Standards showed that disposition (the transfer) status would be documented.

On 5/17/10, Patient 35's medical record was reviewed. The medical record showed the patient was a minor, resided in a group home, and was brought in by ambulance. The patient was subsequently transferred to another hospital.

The medical record contained a section titled "ED/Urgent Care Nursing Data Base and Flow Record." In that section there was a subsection where the name of person notified of admission/transfer, their relation to the patient and their phone number was to be recorded. This subsection was left blank. RN F, who was assisting with the record review, acknowledged the absence of documentation showing transfer notification to the patient's responsible party.

Based on observation, interview, and record review, the hospital failed to provide visual and auditory privacy in the ED for all the patients being triaged in Room six. This resulted in protected health information (PHI) being visible and audible to other patients and visitors when the nursing staff obtained it from the patients.

Findings:

1. During an observation of the ED on 5/13/10 at 1000 hours, the ED Adult Waiting Room six was entered and inspected. MD C was in accompaniment. MD C stated the nursing staff provided medical screening assessments for the patients there.

Observed were three assessment tables with an RN at each table. The table had a computer terminal and monitor. An RN was inputting data regarding the patients' health status. The RN's were interviewing the patients they were seeing regarding current health concerns including history of illness, current medications, and previous hospitalizations.

Approximately six feet across from the tables was a row of ten chairs. All chairs faced the assessment area. The chairs were occupied by patients waiting to be seen by the RN. There was no screen between the assessment table locations and patients waiting in the chairs. At this time a verbal inquiry by the nurse to a patient at the tables and the response by the patient could easily be heard by patients sitting and waiting to be seen.

At the back of the room three lounge type chairs were observed. MD C stated these chairs were specific for patients with psychiatric symptom presentation. One chair was observed within four feet of the screening area and the computer terminal could easily be observed by the patient who occupied this chair. Conversations were audible between the nurse and patient at this location.


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2. During a subsequent observation of the ED Adult Waiting Room Six on 5/14/10 at 1355 hours, CNA A was observed sitting at a computer table at the back of the room near the three lounge chairs. The CNA stated she was taking the vital signs of the patient's waiting to be seen by the physician. The CNA stated she called the patients to her table every two hours when vital signs were due. Following the vital signs, the CNA had the patients sit in the row of chairs opposite the computer tables to wait for the nurse to perform an assessment.

Observation of a nurse at the computer table at the front the screening area, six feet away from the row of chairs showed the nurse asking questions of a patient sitting in a chair next to her desk. When standing at a distance equal to the distance from the row of chairs to the nurse's table, the surveyor could easily hear the nurse's questions to the patient as well as the patient's answers regarding the medical history and symptoms.

Based on observation, interview and review of hospital P&Ps, the hospital failed to ensure medical supplies were stored in a safe manner when needles and syringes were found accessible to patients, visitors and unlicensed staff in unlocked cabinets. This had the potential for patient injury.

Findings:

A review of the policy titled, Emergency Department Supplies, showed articles used for treatment (e.g. needles, syringes) were not to be stored in patient care rooms/areas unless under direct observation of staff. Unsupervised patients may pose a security risk as theft of the needles and syringes represents a health and safety concern for the community.

1. On 5/17/10 at 1410 hours, the West Pod of the Emergency Department was inspected. Accompanying the tour and inspection was the Director of the Emergency Department.

Room 12 was inspected and found to have no staff in the room and a unlocked cart with a sign that showed the following: "For Obvious Reasons no syringes or needles are to be kept in this cart." Labeling on the individual draws of the cart showed the following: intravenous needles, needles for blood drawing, insulin syringes. The cart had a sliding rail with a hole in the end of it for the purpose of locking and securing the contents of the cart. The rail was lifted and found to be unlocked.

The drawers were opened and inspected. Contained within the drawer labeled intravenous needles were approximately 50 intravenous needles. The drawer labeled needles was inspected and had a box of approximately 100 needles for blood specimen acquisition.

A third drawer was inspected and found to have a box of approximately 50 individually wrapped insulin syringes with needles attached.

Within the room were two patients that were sitting in chairs and waiting to be assisted by the emergency room staff. One patient was sitting within one foot of the cart and the other was approximately six feet from the cart.

An interview with RN I was conducted and she stated the cart should be locked and stored safely.


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2. The West Pod of the ED was observed on 5/14/10 at 1420 hours, accompanied by RN J. A cart was observed in the hallway positioned next to and opposite the patient care bays. There were no staff observed caring for the patients at this time. Two clear plastic bins at the top of the cart contained approximately 100 needles used to draw blood for laboratory tests. There were three plastic drawers in the bottom of the cart. The top drawer stored one box of approximately 100 finger stick needles and one box each of three different sizes of IV needles. The second drawer contained approximately 100 Tuberculin syringes, 100 needles and 20 syringes of normal saline. The third drawer contained approximately fifty 20 ml syringes and 50 needles. When asked, RN J stated the cart was usually stored in a locked utility room or under the supervision of a licensed nurse when in use in the patient care area.

Based on interview and record review, the hospital failed to provide a patient care environment free from sexual and verbal abuse for one of 54 patients reviewed (Patient 38). Following a patient's a formal complaint/allegation to the hospital about sexual harassment, the hospital failed to protect future patients while the incident was investigated. This could potentially result in future abuse for other patients.

Findings:

A review of the P & P titled: Sentinel/Critical Clinical Event Reporting, Investigation, and Follow-up, showed sentinel events include staff sexual misconduct with a patient. In addition, an intensive assessment by the Office of Risk Management, Quality Improvement, and others as appropriate, shall conduct an intensive assessment. The intensive assessment shall demonstrate that a comprehensive clinical and administrative review of the event has occurred. The P&P showed corrective actions shall be defined and accompanied by planned implementation dates.

A P&P titled: Internal Complaint Process, showed a sexual harassment complaint need not be in writing for an investigation to be initiated. Documentation showed that to ensure the alleged sexual harassment action and/or behavior ceases, immediate action must be taken. The document failed to show what action would be taken immediately.

The hospital failed to provide evidence immediate action had been taken to protect the health and safety of patients and ensuring that patients were free from future abuse while the allegations were investigated.

On 5/18/10, a review of a complaint allegation began. A letter dated 3/1/10, from Patient 38, showed allegations of three separate incidents of sexual inappropriateness on the part of a care provider. Documentation showed the allegation consisted of Patient 38 stating he was touched on his "butt" by a physician. Documentation also showed Patient 38 alleged a physician inquired if he (the patient) wanted him (the physician) to assist with masturbation.

An interview with the Medical Director was conducted on 5/24/10. The Director was asked about the grievance process and procedures in place to protect patients from abuse. The Director stated she was familiar with this case and there was a determination the allegations had no merit. The Director stated if a employee or staff member was accused of inappropriate conduct while on the premises she would have them escorted off the premises by the hospital police pending the outcome of an investigation. The Director could not say what was done to protect patients while the investigation was completed.

An interview with the RM (Risk Manager) was conducted on 5/25/10 and 5/28/10. The RM was asked about what the hospital did to protect other patients or what plan was initiated as a result of the grievance that was filed on 3/1/10. The RM stated this particular case had a history. She would not elaborate as to the nature of the investigation, or the outcome and findings. She stated she was gathering information about what the hospital's response was to the allegations in order to determine what part of the policy was followed and what portion of the policy was not. The RM stated because of the patient's history and behavior, the hospital's response was to refer the case for investigation to an outside agency.

Based on observation, interview and record review, the hospital failed to ensure the medical staff was accountable for the quality of care provided to 10 of 54 sampled patients in the ED (Patients 1, 2, 4, 11, 19, 35, 37, 40, 49 and 50) and any patient potentially exposed to one mental health physician. The medical staff failed to ensure implementation of the time out P&P during a surgical procedure for Patient A resulting in a wrong site surgery. The medical staff failed to ensure implementation of P&Ps and standards of practice for aneshtesia care provided to Patient B resulting in brain injury.

Findings:

1. The medical staff failed to ensure three of 54 sampled patients were seen for a medical screening examination in a timely manner resulting in a delay in determining if the three patients had an emergency medical condition (Patients 2, 37 and 50) - See A 1104.

2. The medical staff failed to ensure policies and procedures for nursing triage and ongoing care were implemented resulting in potential changes in patient conditions not being recognised for six of 54 sampled patients (Patients 1, 2, 4, 11, 37, and 50) - See A 1104.

3. The medical staff failed to ensure ED records for four of 54 sampled patients were documented in accordance with hospital P&P resulting in potential information not being available to care givers, responsible parties, and patients (Patients 19, 35, 40 and 49) - See A 438.

4. The medical staff failed to ensure patients were protected during the investigation of an allegation of inappropriate sexual conduct by a physician reported by a patient resulting in the potential for further misconduct with patients - See A 145.

5. The medical staff failed to ensure implementation of P&Ps for surgery and anesthesia services - See A 951 and A 1002.

Based on interview and record review, the hospital failed to accurately assess and reassess two of 54 sampled patients (Patients 18 and 50) which resulted in a delay in the MSE (a medical exam used to determine if a patient has an emergency medical condition) for one patient (Patient 50) and a Level 3 acuity assigned to a non-emergent patient (Patient 18). The hospital failed to do timely nursing reassessments for six of 54 patients reviewed (Patients 1, 2, 4, 11, 37, and 50) which could potentially result in unrecognized/untreated changes in patient condition. Additionally, the hospital failed to follow policies and procedure for patient transfer and disposition for two of 54 sampled patients (Patients 35 and 52) which could result in miscommunication between caregivers and responsible parties.

Findings:

On 5/11/10, the Department received a complaint that patients' vital signs were not being taken every two hours.

On 5/13/10, a review of the hospital's P&P #3; subject Triage, page 1 stated the purpose of triage was to categorize patients based on the severity of their injuries or illness, and to prioritize their need for treatment.

The Triage Nursing Team consisted of a router, secondary assessment nurses, and reassessment nurses. The router triage nurse would determine the level of severity based on clinical presentation and chief complaint and route the patient to the secondary triage location for assessment, a patient care room or to resuscitation. Page 2 indicated the secondary triage nurse would perform a more comprehensive assessment of the patient upon arrival including: presenting chief complaint, signs/symptoms, general appearance, vital signs, and any other investigation judged necessary to classify the patient into one of five categories using the Emergency Severity Index (ESI). The reassessment nurse should provide first aid and treatment as indicated. Vital signs should be obtained at a minimum of every two hours for patients who were categorized as having an acuity level of 3. Patients with acuities greater than 3 would be reassessed on an ongoing basis.

Review of Attachment #1 on the triage policy showed that acuity Level 1 would be patients requiring immediate life-saving interventions. Acuity Level 2 would be patients who were a high risk situation, confused, lethargic, disoriented or unresponsive, nonverbal and not following commands. Acuity Level 3 were patients with danger zone vitals such as heart rate greater than 100-180, respiratory rate greater than 20-50 and oxygen saturation (oxygen in the blood) less than 92% and requiring multiple resources. Acuity Level 4 and 5 were the least urgent patients who could be seen in a fast track or urgent care center rather than the main ED. Acuity Level 4 had more resources required such as laboratory and radiology tests than Acuity Level 5.

1. During an observation of the ED Adult Waiting Room Six on 5/13/10 at 1110 hours, Patient 50 was interviewed. The patient stated she had "brain surgery" last week and passed out this morning. The patient stated she had arrived in the ED by ambulance at 0430 hours and was triaged by the RN quickly as an Acuity Level 3. As of 1120 hours, the patient stated she had been reassessed only once by the nurse since 0430 hours. The patient stated she had not been told how long it would be before she saw a physician, but stated she "almost wanted to leave."

RN B was interviewed on 5/13/10 at 1115 hours. The RN confirmed he was one of the nurses assigned to ED Adult Waiting Room Six that day. When asked how often patients were reassessed after triage, the RN stated every two hours, or more often if the condition of the patient warranted it. When asked how long the wait was for patients to be seen by a physician, the RN stated the longest patient waiting was 16 hours when he arrived to work that morning. The RN stated this was not an uncommon wait time.

RN C was interviewed on 5/13/10 at 1120 hours. The RN was sitting at a triage station in the ED Adult Waiting Room Six. When asked about the wait time to be seen by a physician, the RN turned to the computer monitor and pointed on the screen to show four patients waiting at the 15 hour mark. The RN was asked to show the reassessment times for Patient 50. The computer monitor documentation showed Patient 50 had arrived in the ED at 0429 hours and was immediately triaged. The patient had been reassessed with vital signs at 0802 hours and a nursing assessment that included the patient complaint of being confused. There was no documentation to show vital signs had been reassessed since that time. The RN stated vital signs were to be repeated every two hours. When asked, the RN acknowledged the patient should have been reassessed for a total of three times since the triage assessment.

The patient's medical record was again reviewed on 5/17/10 and showed Patient 50 arrived in the ED at 0427 hours and was triaged at 0429 hours. Also, in addition to the nursing reassessments noted above at 0802 hours, the other nursing reassessments were at 1308 hours and 1754 hours. The patient received an MSE at 1940 hours on 5/17/10, more than 17 hours since arrival to the ED.

Further review of Patient 50's history in the medical record showed on 5/5/10 the patient had a ventricular shunt placed (a tube that is surgically placed in one of the fluid-filled chambers inside the brain (ventricles) to drain it and thereby relieve excess pressure) and had been brought into the ED on 5/13/10 by ambulance after "passing out" in her parents' arms.

2. The medical record for Patient 2 was reviewed on 5/14/10. Documentation showed the patient arrived in the ED on 5/4/10 at 0832 hours. Triage by the RN was documented as completed at 0807 hours. The patient stated she had been diagnosed with a cerebral vascular accident (stroke) on 4/30/10, and had been referred to this hospital for further follow-up and neurology consult. On arrival in the ED the patient complained of a headache with "ringing" in her right ear. Documentation showed the patient had left sided weakness to the upper and lower extremities. Vital signs showed a blood pressure of 151/82, pulse was 82 and the respiratory rate was 18. The patient's oxygen saturation level measured 100% on room air. The triage RN assessed the patient as Acuity Level 3. Documentation showed the patient left the ED without being seen by a physician on 5/5/10 at 0023 hours. Further review of the medical record did not show documentation the patient had been reassessed nor had vital signs been recorded following triage at 0807 hours on 5/4/10.

During an interview with RN I on 5/17/10 at 1125 hours, the medical record for Patient 2 was reviewed. The RN provided documentation of an electronic screen shot which showed the patient had been called for further reassessment on 5/4/10 at 1518 hours. The patient was called again at 1628 and 2109 hours, but had not responded. The RN was asked when a patient should be reassessed by the nurse if presenting with a history of a stroke and an onset of a headache and ringing in the ear. RN I stated she was not able to state in this case, however vital signs should have been checked every two hours following the triage assessment, as the patient was an Acuity Level 3.

3. On 5/14/10, a review of Patient 18's medical record showed the patient arrived in the ED at 0856 hours on 5/10/10 and was triaged as a Level 3 acuity at 0940 hours. The patient's chief complaint was eye discharge and blurry vision times three days. The initial vital signs taken at triage time were within normal ranges and were not repeated again prior to the patient's discharge on 5/10/10 at 1734 with a diagnosis of conjunctivitis. As noted in the P&P Level 3 Acuity patients require vital signs every two hours to monitor for vital signs in the danger zone, a symptomatology that did not correspond with the patient's diagnosis.


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4. On 5/17/10, the medical record review of Patient 1 was conducted with RN G. Patient 1 presented in the ED on 4/1/10 at 0951 hours. The triage nurse assessed Patient 1 at 1000 hours as Acuity Level 2. Patient 1 had difficulty expressing self with memory loss 4 days ago. On 4/1/10, the clinical notes revealed Patient 1 was reassessed on an ongoing basis as resting with no acute distress until 2220 hours.

On 4/1/10 at 2350 hours, with the help of an electronic interpreter, it was documented Patient 1 was feeling numbness to his right foot and leg below the knee. The Physician's Assistant (PA) was made aware of the patient's status; however, the vital signs taken at 0000 hours were not repeated until 0645 hours. There was no additional mental status assessment. The frequency of vital signs for Acuity Level 2 per the hospital's policy was every two hours.

On 5/17/10 at 0930 hours, RN G acknowledged that the frequency of vital signs and patient assessment should have been more frequent to ensure the patient's status did not deteriorate.

5. Patient 11 was brought in to the ED via an ambulance on 3/2/10 at 1813 hours. On arrival, the patient was triaged as an Acuity Level 3, with potential for self harm per the nursing care plan. However, the vital signs were taken every 4-7 hours (1923 hours, 2326 hours and 0739 hours) instead of every two hours per hospital's policy. In addition, the nursing progress notes were only documented during the arrival of the patient in the ED and at the patient's departure from the ED on 3/3/10 at 1350 hours.

On 5/17/10 at 1000 hours, RN G acknowledged the lack of documentation to show the RN's assessment and supervision of Patient 11.


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6. On 5/14/10, a review of Patient 4's medical record showed, on a demographic form, the patient arrived to the ED on 5/4/10 at 1230 hours and was triaged at 1250 hours as a Level 3. There was no documentation of a two hour reassessment at 1450 hours. A status report on 5/4/10 at 1656 hours showed the patient's status as NA/1. According to RN F, N/A1 meant the patient was called by an ED staff member to be seen and did not respond.

7. Review of Patient 37's medical record on 5/14/10, showed he arrived in the ED on 5/12/10 at 2345 hours. The patient was triaged at 2353 hours. The patient complained of diffuse abdominal pain with increasingly bloody stools. The patient stated he had history of a hernia. Vital signs were completed and a hemoglobin test was completed with the results of 14.7 g/dL, within normal limits. The patient was assigned an Acuity Level 3. There was no further documentation to show vital signs and reassessment were conducted following the triage assessment.

Further review of Patient 37's medical record showed, in the physician's ED notes, no MSE was conducted until 1730 hours on 5/13/10 which was 17 hours after the patient's arrival in the ED.

8. On 5/17/10, review of the hospital's discharge policy and procedure titled Department of Emergency Medicine: Nursing Services Unit Structure Standards showed that disposition status will be documented.

On 5/17/10, Patient 35's medical record was reviewed. The medical record showed the patient was a minor, resided in a group home, and was brought in by ambulance. The patient was subsequently transferred to another hospital.

The medical record contained a section titled "ED/Urgent Care Nursing Data Base and Flow Record." In that section there was a subsection where the name of person notified of admission/transfer, their relation to the patient and their phone number was to be recorded. This subsection was left blank. RN F, who was assisting with the record review, acknowledged the absence of transfer notification to the patient's responsible party.


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9. A review of the Department of Emergency Medicine: Nursing services Unit Structure Standards showed that disposition status would be documented.

A review of Patient 52's medical record began on 5/17/10, and showed on page two of the Emergency Medicine Consult form, an area for documenting disposition, date and time. This section of this document was blank.

On the left hand column was a section titled: MDM/Attending/Progress/Procedure Notes. The form directed the physician/psychiatrist to time all notes. Documentation in this section showed patient appeared well, had no medical complaints, and refused an exam. May send to psychiatry. There was no time or date when the note was written.

An interview with RN I was conducted and she stated the form was incomplete and should have disposition, date and time. She stated, "This is our policy."

Based on interview and medical record review, the hospital failed to ensure a discharge plan of care was developed and discharge instructions were issued to one of 54 sampled patients (Patient 28). The patient was discharged from the ED following the insertion of an indwelling urinary drainage catheter due to urinary retention. No documentation was found to show a discharge plan was developed appropriate to the patient's physiological and psychosocial status and the patient instructed in the care and handling of the catheter. This had the potential to result in infection from the urinary catheter and injury to the patient.

Findings:

Review of the hospital P&P for Operational Issues, Patient Teaching/Aftercare Instructions, showed upon discharge the patient would be given the ED Instruction sheet explaining treatments and services provided during the visit, follow-up clinic appointments and other follow-up care as needed.

The medical record for Patient 28 was reviewed on 5/14/10. The patient arrived in the ED on 3/23/10 at 1306 hours. The patient complained of being unable to urinate since last night. Documentation showed the patient had a history of mental illness and had attempted to pass urine by inserting a screw in his urethra.

Review of the ED Nursing Data Base and Flow Record form for Patient 28 showed documentation on 3/23/10 at 1530 hours, the RN was unable to insert an indwelling urinary drainage catheter after two attempts. A urologist was called to consult. An indwelling urinary drainage catheter was inserted by the physician at 1905 hours. Documentation on 3/23/10 at 1930 hours, showed the patient was discharged alert and oriented times four, had a steady gait, positive pulses, his skin was warm and dry to touch and he had no shortness of breath. In the area at the bottom of the nursing flow record documentation showed the patient was discharged home at 1939 hours, had verbalized understanding of discharge instructions and an appointment was given with urology. There was no documentation to show an indwelling urinary catheter in place at the time of discharge.

Review of the ED discharge instructions given to Patient 28 dated 3/23/10, showed a diagnosis of urinary retention. There was no documentation found on the discharge instructions or in the medical record to show the patient was instructed in the home care of an indwelling urinary drainage catheter. The patient was informed he would be mailed a follow-up appointment for the urology clinic.

The electronic and paper medical record was reviewed with RN I on 5/14/10 at 1015 hours. When asked to review the ED nursing notes to show if an indwelling urinary catheter was in place at the time of discharge 3/23/10, the RN I stated the nursing notes were not clear as to that fact. When asked to locate documentation to show the patient was instructed in the care of an indwelling urinary drainage catheter, RN I stated she was unable to do so. Further review of the patient's medical record showed a subsequent ED visit on 4/7/10. The patient presented to the ED stating he had never received a follow-up appointment for the urology clinic and he requested the indwelling urinary catheter be removed.

Based on observation and document review, the hospital failed to ensure a medication was wasted (disposed of) according to the hospital's policy and procedure. This has the potential for unsafe hazardous waste disposal.

Findings:

On 5/18/10, a review of the hospital's policy and procedure titled "Handling of Expired, Deteriorated, Discontinued, Recalled or Otherwise Unwanted Drugs" showed partially used controlled substance ampules were to have the remaining liquid withdrawn into a syringe then the liquid expressed into a blue pharmaceutical waste container.

On 5/18/10 at 1410 hours, RN D was observed drawing up and administering 6 mg of a 10 mg vial of morphine sulfate to Patient 53. RN E, who was present during the administration, took the vial with the remaining 4mg of morphine sulfate and discarded it into the sharps container on the wall behind the patient.

Based on interview and medical record review, the hospital failed to maintain complete medical records. For three of 54 sampled patients (Patients 19, 40 and 49) there was no documentation to show the time the initial MSE was done by the physician. This could potentially result in inaccurate communication between providers. For one of 54 sampled patients (Patient 35) there was no documentation to show the hospital notified a responsible party of the minor patient's admission to the hospital. This could potentially result in difficulty for the responsible party to locate the patient.

Findings:

Review of the hospital P&P for Operational Issues, Physician Documentation, showed all entries were to be dated and timed.

1. The electronic and paper medical record for Patient 49 was reviewed on 5/14/10 with RN A. The patient had presented to the ED on 5/13/10 at 0803 hours. Review of the ED Record form used by the physicians did not show documentation of the date and time when the initial MSE was conducted.


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2. On 5/17/10, a review of the medical record showed Patient 19 was admitted to the ED on 2/26/10 at 1323 hours and was triaged by the RN at 1355 hours. The MSE time was not documented. RN F, who was assisting with the medical record review, acknowledged there was no MSE time documented.

3. On 5/17/10, review of the hospital's discharge policy and procedure titled Department of Emergency Medicine: Nursing Services Unit Structure Standards showed that disposition status would be documented.

On 5/17/10, Patient 35's medical record was reviewed. The medical record showed the patient was a minor, resided in a group home, and was brought in by ambulance. The patient was subsequently transferred to another hospital.

The medical record contained a section titled "ED/Urgent Care Nursing Data Base and Flow Record." In that section there was a subsection where the name of person notified of admission/transfer, their relation to the patient, and their phone number was to be recorded. This subsection was left blank. RN F, who was assisting with the record review, acknowledged the absence of documentation showing transfer notification to the patient's responsible party.


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4. Review of Patient 40's electronic and paper medical records was conducted on 5/17/10 with RN G. Patient 40 presented in the ED on 5/13/10 at 1122 hours. The patient was seen by the triage nurse at 1125 hours and by the ED physician on the same day. However, the time the ED physician examined the patient was left blank.

Based on interview and record review, the hospital failed to ensure a health screening for TB (tuberculosis) was done for one of 15 employee files reviewed. This could potentially result in exposure to TB for patients and hospital staff.

Findings:

According to the Communicable Disease Center Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Setting, 2005, page 3, HCWs refer to all paid and unpaid persons working in health-care settings who have the potential for exposure to M. tuberculosis through air space shared with persons with infectious TB disease. All HCWs who have duties that involve face-to-face contact with patients with suspected or confirmed TB disease should be included in a TB screening program.

According to the Communicable Disease Center Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Setting, 2005, page 10, "the classification of medium risk should be applied to settings in which the risk assessment has determined that health care workers (HCW) will or will possibly be exposed to persons with TB disease or to clinical specimens that might contain M. tuberculosis. The recommendations for medium risk included, "All HCWs should receive baseline TB screening upon hire." "After baseline testing for infection, HCWs should receive TB screening annually."

On 5/18/10 during a review of employee files, RN H (an emergency room RN) did not have
evidence of annual TB screening. HR A was unable to provide documentation of TB screening for RN H prior to the survey exit.

Based on interview and record review the hospital failed to ensure a time-out procedure to verify the patient's identity and site and side of the surgical procedure for one of one patient reviewed. (Patient A). This resulted in revascularization (a procedure to restore arterial blood flow) being performed on the wrong leg and a delay in treatment of the correct leg.

Findings:

The hospital failed to ensure a time out procedure was performed prior to the beginning of Patient A's procedure and when the anesthesiologist was called in to provide anesthesia because the patient could not tolerate the procedure. See A 951.

The failure to implement policies and procedures designed to ensure patient safety during surgery resulted in the hospital's inability to provide surgical services in a safe environment.

Based on interviews, review of hospital documents, and a review of the closed medical record for Patient A, the hospital failed to ensure the "time out" policy and procedure was implemented for Patient A. A "time out" is conducted to verify the patient's identity, and the site and side of the body to be operated on. Failure to follow the P&P resulted in the wrong leg of Patient A being treated. The tissues of Patient A's toe were dying and a procedure to correct the patient ' s blood flow to the left toe was scheduled. Instead, the procedure was performed on the patient's right leg. This subjected Patient A to the risks of general anesthesia and another invasive procedure one week later and did not provide treatment of the dying toe in a timely manner.

Findings:

According to interviews with MD X at approximately 1100 hours, on 5/10/10, and a review of the closed medical record for Patient A, Patient A underwent interventional angiography on 4/16/10. Angiography is a procedure in which blood vessels (arteries or veins) are injected with a dye that shows up on x-ray to detect narrowing or blockages. The procedure may include treatment (Interventional Angiography) which includes inserting a small tube to inflate and open the vessel.

Patient A's procedure was performed by an interventional cardiologist in the Cardiac Catheterization Laboratory (cath lab). According to MD X, Patient A was brought to the cath lab for the procedure and the patient was turned the opposite direction from the usual patient position, in order to perform a distal (toward the toes) angiographic study. When interviewed, MD X stated that Patient A was known to have diffuse, occlusive, vascular disease with a necrotic left great toe (widespread narrowing of the blood vessels causing death of the cells and tissue in the toe). MD X stated that the interventional angiography procedure was initiated under local anesthesia with mild sedation. A right femoral artery approach was performed. MD X stated that Patient A became restless and was unable to remain still, for the procedure. For this reason, the Anesthesia Department was called. According to the anesthesia record, the attending anesthesiologist wrote: "called to cardiac cath lab for patient with Right Lower extremity ischemia, patient not tolerating sedation with movement."

General anesthesia was initiated "without difficulty," at 1550 hours on 4/16/10. Surgery concluded at 1820 hours. A review of the anesthesia record and interviews with MD X revealed that no surgical "time out" occurred at the time the anesthesiologist attended Patient A to ensure the appropriate site, side and identity of the patient. MD X stated that the usual policy and procedure to provide a time out, prior to the anesthesiologist providing care had not been done, in violation of the policy and procedure of the hospital that requires a surgical time out prior to initiating a procedure.

An interval note placed in the medical record at 2130 hours on 4/16/10, revealed that an atherectomy (removal of a plaque causing a narrowed segment of the artery) was performed on the right side, rather than on the left side, the side and site of the necrotic left great toe. MD X stated that he notified the family and the patient of the wrong site and side of the procedure and the decision was made to perform the angiogram on the left side the following week. On 4/19/10 Patient A was returned to the cath lab for interventional angiography performed under general anesthesia with his respirations assisted by a breathing tube. Patient A tolerated the second procedure without complication.

Based on interview and record review, the hospital failed to ensure anesthesia was administered in accordance with hospital policies and procedures and/or standards of practice for two of two patients reviewed . (Patients A and B).

Findings:

The hospital failed to ensure implementation of the P&P for supervision of CRNA X during anesthesia administration for Patient B. In addition, the CRNA did not ensure care provided to Patient B followed the standard of practice for airway management established by the American Society of Anesthesiologists. This resulted in brain injury for Patient B. See A 1002 #1.

The hospital failed to ensure the P&P for a surgical "time out" was implemented for Patient A. This resulted in the procedure being done on the wrong leg of Patient A and a delay in treatment. See A 1002 #2.

The cumulative effect of these systemic practices resulted in the inability of the hospital to ensure quality of anesthesia care in a safe environment.

Based on interviews, review of hospital documents and a review of closed medical records the medical staff failed to ensure that policies and procedures for anesthesia care and medical staff consultation prior to induction of anesthesia, were implemented for Patient B. This resulted in a CRNA (Certified Registered Nurse Anesthetist) placing Patient B under general anesthesia without consultation by the supervising physician. Patient B had difficulty breathing while under anesthesia, requiring endotracheal intubation (a medical procedure in which a tube is placed into the windpipe, through the mouth or the nose to assist in breathing). This resulted in a significant change in Patient B's neurological status after surgery.

In addition, for Patient A, the hospital failed to ensure that the person administering anesthesia had verified the patient's identity, and the site and side of the body to be operated on prior to administering anesthesia to Patient A. This resulted in the wrong leg of Patient A being treated. The tissues of Patient A's toe were dying and a procedure to correct the patient's blood flow to the left toe was scheduled. Instead, the procedure was performed on the patient's right leg. This subjected Patient A to the risks of general anesthesia and an invasive procedure one week later and did not provide the treatment of the dying toe in a timely manner.

Findings:

1. On 5/10/10 review of the medical record for Patient B showed that Patient B was admitted to the hospital on 8/25/09 for the treatment of gasoline burns involving both lower and upper extremities, and burns to the front of the chest. Patient B had undergone two prior surgical procedures for debridement and skin grafting. On 9/11/09, Patient B was again scheduled for surgery to undergo an elective procedure to provide a small skin graft to an area of the right lower extremity from a donor site in the right groin.

A review of the pre-anesthetic assessment form, filled in by CRNA X and dated 9/10/09, revealed that Patient B had a diagnosis of "32% Total Body burns to the extremities and neck." Patient B was scheduled for surgery to undergo "split thickness skin graft to the right leg." CRNA X wrote: the "Medical History" revealed that Patient B had consumed ? pack of cigarettes per day for 40 years and he was a "heavy drinker." The physical examination entered by CRNA X revealed that Patient B had "increased secretions" and breath sounds were "clear to auscultation on both sides." CRNA X noted that a "NG" (nasogastric tube) was in place. The vital signs revealed a blood pressure of 104/58, a pulse of 122 bpm (beats per minute - this heart rate is above the normal heart rate of approximately 70 - 90 bpm) and a temperature of 100.3. The laboratory work reviewed by CRNA X and entered into the form revealed 21,200 WBC, 7.9 gm. Hgb., and Albumin of 2.1. (These values reflect that Patient B had an elevated white blood cell count, low hemoglobin and low protein content in the blood). CRNA X wrote that Patient B was assessed as ASA 4, (the American Society of Anesthesiologists assessment level of 4 is a patient with a severe systemic disease, which is a constant threat to life).

The pre-operative report contained a place for the attending physician to sign; however, there was no physician signature present on the record. This indicated no written evidence that MD R, the supervising anesthesiologist, had reviewed or was aware of the pre-anesthetic assessment for Patient B. The hospital's policy and procedure for "Supervision of the CRNA BY THE PHYSICIAN " states "General departmental guidelines permit the CRNA to practice the following procedures under the supervision of an anesthesiologist: Pre-anesthetic assessment of the patient should be co-signed by M.D." There was no written signature of a staff anesthesiologist documented or present on the pre-anesthetic assessment form for Patient B as was required by the hospital policy and procedure for anesthesia. The medical record for Patient B contained no written documentation that a consultation or discussion of the clinical status of Patient B, the lab values, or the planned surgery and anesthesia procedures had been presented to MD R for consultation or discussion. There was no written documentation that either the supervising anesthesiologist or the surgical team had been made aware of these laboratory values, for this elective procedure.

When interviewed at approximately 1015 hours on 5/10/10, both MD R and CRNA X agreed that there was no documentation in the medical record to indicate that CRNA X had been authorized to begin anesthesia induction, as was required by the policy and procedure for CRNA supervision that states "All CRNAs must have an anesthesiologist present for induction for all anesthesia." "If the faculty is busy with another case, permission for a CRNA to begin induction with a resident or alone is needed." "This permission should be documented on the anesthesia record." The anesthesia record revealed no written documentation of such authorization from MD R to CRNA X to begin anesthesia induction.

Anesthesia induction occurred at 1143 hours with 100 mg of propofol (a drug widely used by anesthesia providers to induce general anesthesia). There was no documentation that the hospital policy, to document that CRNA X had been given authorization to proceed with induction by MD R, had been obtained or entered into the medical record, as was required by the policy and procedure of the hospital.

Interviews with MD R at 1115 hours on 5/10/10 revealed that MD R was in another room providing anesthesia services. MD R stated that she was in transit to the operating room for the procedure to be done on Patient B when she received a telephone call from CRNA X. MD R stated that she was informed by CRNA X: "I am going ahead with the case."

When interviewed on 5/10/10, at approximately 1015 hours, CRNA X stated that MD R was not in the operating room at the time that induction of anesthesia occurred, as was required in the policy and procedure from the hospital. However, during an interview conducted with MD R on 5/10/10 at approximately 1115 hours, she stated that she was in the operating room at the time the laryngeal mask anesthesia was placed for Patient B, but then left the room, to attend to another case.

At 1148 hours laryngeal mask anesthesia was begun. The laryngeal mask airway is an alternative airway device used for anesthesia and airway support. A tube is inserted into the patient's throat and a mask attached. It's primary use is for ASA risk class I and II patients. A review of the anesthesia record revealed that Patient B's blood pressure changed from 88/48 mm. Hg. to 77/38 mm. Hg (millimeters mercury).

At 1148 hours phenylephrine (a medication used to maintain blood pressure) was given IV push and at 1149 hours 1000 cc of lactated ringers was infused rapidly IV. There was no documentation in the medical record that CRNA X discussed or informed the surgical team or the supervising physician of the medications being administered to maintain the blood pressure for the patient.

? At 1150 hours, surgery started.
? At 1151 hours phenylephrine and ephedrine (another medicine to help maintain blood pressure) were administered by CRNA X.
? At 1152 hours 400 cc lactated ringers was administered.
? At 1200 hours phenylephrine 40 mcg was given by IV push.
? At 1204 hours lactated ringers 300 cc was administered.
? At 1204 hours Hetastarch 500 ml was administered. (Hetastarch is a plasma volume expander used to maintain blood pressure).
? At 1215 hours a time out was completed to verify the correct patient, procedure and site of the procedure.
? At 1226 hours CRNA X left the operating room for lunch and was relieved by MD S.
? At 1230 hours the surgical incision was made.
? At 1237 hours MD S removed the laryngeal mask anesthesia device to intubate Patient A.
? At 1237 hours the blood pressure was recorded as 40/25 mm. Hg.
? At 1245 hours chest compressions were initiated by the surgeon.
? At 1320 hours chest tubes were placed into both sides of the chest by the surgeon.

According to the medical record and interviews with MD S at approximately 1130 hours on 5/10/10, MD S provided anesthesia services for Patient B, to relieve CRNA X. MD S stated that Patient B became very difficult to ventilate, using the laryngeal mask anesthesia (LMA). MD S stated that he thought that Patient B developed severe bronchospasm resulting in severe hypoxia (low oxygen levels in the blood). MD S withdrew the LMA and intubated Patient B at 1237 hours on 9/11/09. At that point, the heart rate was recorded as 40 beats per minute and the oxygen saturation of the blood at 40. At that point, cardiopulmonary resuscitation was initiated for presumed pulseless electrical activity of the heart and low blood pressure.

Post-procedure notes indicated that Patient B had suffered severe anoxic brain injury (a lack of oxygen to the brain severe enough to cause neurological damage). Patient B remains an inpatient at a rehabilitation facility.

2. According to interviews with MD X at approximately 1100 hours, on 5/10/10, and a review of the closed medical record for Patient A, Patient A underwent interventional angiography on 4/16/10. Angiography is a procedure in which blood vessels (arteries or veins) are injected with a dye that shows up on x-ray to detect narrowing or blockages. The procedure may include treatment (Interventional Angiography) which includes inserting a small tube to inflate and open the vessel.

Patient A's procedure was performed by an interventional cardiologist in the Cardiac Catheterization Laboratory (cath lab). According to MD X, Patient A was brought to the cath lab for the procedure and the patient was turned the opposite direction from the usual patient position, in order to perform a distal (toward the toes) angiographic study. When interviewed, MD X stated that Patient A was known to have diffuse, occlusive, vascular disease with a necrotic left great toe (widespread narrowing of the blood vessels causing death of the cells and tissue in the toe). MD X stated that the interventional angiography procedure was initiated under local anesthesia with mild sedation. A right femoral artery approach was performed. MD X stated that Patient A became restless and was unable to remain still, for the procedure. For this reason, the Anesthesia Department was called.

According to the anesthesia record, the attending anesthesiologist wrote: "called to cardiac cath lab for patient with Right Lower extremity ischemia, patient not tolerating sedation with movement. " General anesthesia was initiated " without difficulty, " at 1550 hours. Surgery concluded at 1820 hours. A review of the anesthesia record and interviews with MD X revealed that no surgical "time out" occurred at the time the anesthesiologist attended Patient A to ensure the appropriate site, side and identity of the patient. MD X stated that the usual policy and procedure to provide a time out, prior to the anesthesiologist providing care had not been done, in violation of the policy and procedure of the hospital that requires a surgical time out prior to initiating a procedure.

Patient A was taken to the recovery area of the hospital at 1909 hours and the breathing tube inserted during the general anesthesia had been removed. An interval note placed in the medical record at 2130 hours on 4/16/10, revealed that an atherectomy (removal of a plaque causing a narrowed segment of the artery) was performed on the right side, rather than on the left side, the side and site of the necrotic left great toe. MD X stated that he notified the family and the patient of the wrong site and side of the procedure and the decision was made to perform the angiogram on the left side, the following week. On 4/19/10 Patient A was returned to the cath lab for interventional angiography performed under general anesthesia with his respirations assisted by a breathing tube. Patient A tolerated the second procedure without complication.

Based on observation, interview and record review, the hospital failed to:

1. Provide timely MSEs to determine if the patient had an emergency medical condition - See A 1104 #1 and #6.

2. Notify a responsible party of a patient's transfer from the ED to another hospital - See A1104 #8.

3. Protect audio and visual privacy in ED Triage Room 6 - See A 143.

4. Ensure a safe environment in the ED when syringes and needles were available to patients. - See A 144.

5. Provide accurate triage nursing assessments and timely reassessments for six of 54 sampled patients ED patients - See A 1104 #1, #2, #3, #4, #5, and #6.

6. Follow policy and procedure for two of 54 sampled patients for disposition from the ED - See A 1104 # 7 and #8.

The cumulative effect of these systemic problems resulted in the hospital's inability to ensure the provision of quality health care in a safe environment.

Based on observation, interview, and medical record review, the hospital failed to provide a timely medical screening examination for three of 54 sampled patients (Patients 2, 37 and 50). This resulted in the failure to ensure the patient were assessed in a timely manner to determine if an emergency medical condition existed.

The hospital failed to ensure the triage (assignment of need for medical treatment) P&P was implemented correctly for one of 54 sampled patients resulting an Acuity Level 3 assigned to a non-emergent patient (Patient 18).

The hospital failed to do timely nursing reassessments for six of the 54 patients reviewed (Patients 1, 2, 4, 11, 37, and 50) which could potentially result in unrecognized/untreated changes in patient condition.

In addition, the hospital failed to follow ED nursing P & Ps for patient transfer and disposition
for two of 54 sampled patients (Patients 35 and 52) which could potentially result in miscommunication among caregivers and responsible parties.

Findings:

On 5/11/10, the Department received a complaint that patients' vital signs were not being taken every two hours.

On 5/13/10, a review of the hospital's P&P #3; subject Triage, page 1 stated the purpose of triage was to categorize patients based on the severity of their injuries or illness, and to prioritize their need for treatment.

The Triage Nursing Team consisted of a router, secondary assessment nurses, and reassessment nurses. The router triage nurse would determine the level of severity based on clinical presentation and chief complaint and route the patient to the secondary triage location for assessment, a patient care room or to resuscitation. Page 2 indicated the secondary triage nurse would perform a more comprehensive assessment of the patient upon arrival including: presenting chief complaint, signs/symptoms, general appearance, vital signs, and any other investigation judged necessary to classify the patient into one of five categories using the Emergency Severity Index (ESI). The reassessment nurse should provide first aid and treatment as indicated. Vital signs should be obtained at a minimum of every two hours for patients who were categorized as having an acuity level of 3. Patients with acuities greater than 3 would be reassessed on an ongoing basis.

Review of Attachment #1 on the triage policy showed that acuity Level 1 would be patients requiring immediate life-saving interventions. Acuity Level 2 would be patients who were a high risk situation, confused, lethargic, disoriented or unresponsive, nonverbal and not following commands. Acuity Level 3 were patients with danger zone vitals such as heart rate greater than 100-180, respiratory rate greater than 20-50 and oxygen saturation (oxygen in the blood) less than 92% and requiring multiple resources. Acuity Level 4 and 5 were the least urgent patients who could be seen in a fast track or urgent care center rather than the main ED. Acuity Level 4 had more resources required such as laboratory and radiology tests than Acuity Level 5.

1. During an observation of the ED Adult Waiting Room Six on 5/13/10 at 1110 hours, Patient 50 was interviewed. The patient stated she had "brain surgery" last week and passed out this morning. The patient stated she had arrived in the ED by ambulance at 0430 hours and was triaged by the RN quickly as an Acuity Level 3. As of 1120 hours, the patient stated she had been reassessed only once by the nurse since 0430 hours. The patient stated she had not been told how long it would be before she saw a physician, but stated she "almost wanted to leave."

RN B was interviewed on 5/13/10 at 1115 hours. The RN confirmed he was one of the nurses assigned to ED Adult Waiting Room Six that day. When asked how often patients were reassessed after triage, the RN stated every two hours, or more often if the condition of the patient warranted it. When asked how long the wait was for patients to be seen by a physician, the RN stated the longest patient waiting was 16 hours when he arrived to work that morning. The RN stated this was not an uncommon wait time.

RN C was interviewed on 5/13/10 at 1120 hours. The RN was sitting at a triage station in the ED Adult Waiting Room Six. When asked about the wait time to be seen by a physician, the RN turned to the computer monitor and pointed on the screen to show four patients waiting at the 15 hour mark. The RN was asked to show the reassessment times for Patient 50. The computer monitor documentation showed Patient 50 had arrived in the ED at 0429 hours and was immediately triaged. The patient had been reassessed with vital signs at 0802 hours and a nursing assessment that included the patient complaint of being confused. There was no documentation to show vital signs had been reassessed since that time. The RN stated vital signs were to be repeated every two hours. When asked, the RN acknowledged the patient should have been reassessed for a total of three times since the triage assessment.

The patient's medical record was again reviewed on 5/17/10 and showed Patient 50 arrived in the ED at 0427 hours and was triaged at 0429 hours. Also, in addition to the nursing reassessments noted above at 0802 hours, the other nursing reassessments were at 1308 hours and 1754 hours. The patient received an MSE at 1940 hours on 5/17/10, more than 17 hours since arrival to the ED.

Further review of Patient 50's history in the medical record showed on 5/5/10 the patient had a ventricular shunt placed (a tube that is surgically placed in one of the fluid-filled chambers inside the brain (ventricles) to drain it and thereby relieve excess pressure) and had been brought into the ED on 5/13/10 by ambulance after "passing out" in her parents' arms.

2. The medical record for Patient 2 was reviewed on 5/14/10. Documentation showed the patient arrived in the ED on 5/4/10 at 0832 hours. Triage by the RN was documented as completed at 0807 hours. The patient stated she had been diagnosed with a cerebral vascular accident (stroke) on 4/30/10, and had been referred to this hospital for further follow-up and neurology consult. On arrival in the ED the patient complained of a headache with "ringing" in her right ear. Documentation showed the patient had left sided weakness to the upper and lower extremities. Vital signs showed a blood pressure of 151/82, pulse was 82 and the respiratory rate was 18. The patient's oxygen saturation level measured 100% on room air. The triage RN assessed the patient as Acuity Level 3. Documentation showed the patient left the ED without being seen by a physician on 5/5/10 at 0023 hours. Further review of the medical record did not show documentation the patient had been reassessed nor had vital signs been recorded following triage at 0807 hours on 5/4/10.

During an interview with RN I on 5/17/10 at 1125 hours, the medical record for Patient 2 was reviewed. The RN provided documentation of an electronic screen shot which showed the patient had been called for further reassessment on 5/4/10 at 1518 hours. The patient was called again at 1628 and 2109 hours, but had not responded. The RN was asked when a patient should be reassessed by the nurse if presenting with a history of a stroke and an onset of a headache and ringing in the ear. RN I stated she was not able to state in this case, however vital signs should have been checked every two hours following the triage assessment, as the patient was an Acuity Level three.

3. On 5/17/10, the medical record review of Patient 1 was conducted with RN G. Patient 1 presented in the ED on 4/1/10 at 0951 hours. The triage nurse assessed Patient 1 at 1000 hours as Acuity Level 2. Patient 1 had difficulty expressing self with memory loss 4 days ago. On 4/1/10, the clinical notes revealed Patient 1 was re-assessed on an ongoing basis as resting with no acute distress until 2220 hours.

On 4/1/10 at 2350 hours, with the help of an electronic interpreter, it was documented Patient 1 was feeling numbness to his right foot and leg below the knee. The Physician's Assistant (PA) was made aware of the patient's status; however, the vital signs taken at 0000 hours were not repeated until 0645 hours. There was no additional mental status assessment. The frequency of vital signs for Acuity Level 2 per the hospital's policy was every two hours.

On 5/17/10 at 0930 hours, RN G acknowledged that the frequency of vital signs and patient assessment should have been more frequent to ensure the patient's status did not deteriorate.

4. Patient 11 was brought in to the ED via an ambulance on 3/2/10 at 1813 hours. On arrival, the patient was triaged as an Acuity Level 3, with potential for self harm per the nursing care plan. However, the vital signs were taken every 4-7 hours (1923 hours, 2326 hours and 0739 hours) instead of every two hours per hospital's policy. In addition, the nursing progress notes were only documented during the arrival of the patient in the ED and at the patient's departure from the ED on 3/3/10 at 1350 hours.

On 5/17/10 at 1000 hours, RN G acknowledged the lack of documentation to show the RN's assessment and supervision of Patient 11.

5. On 5/14/10, a review of Patient 4's medical record showed, on a demographic form, the patient arrived to the ED on 5/4/10 at 1230 hours and was triaged at 1250 hours as an Acuity Level 3. There was no documentation of a two hour reassessment at 1450 hours. A status report on 5/4/10 at 1656 hours showed the the patient's status as NA/1. According to RN F, N/A1 meant the patient was called by an ED staff member to be seen and did not respond.

6. Review of Patient 37's medical record on 5/14/10, showed he arrived in the ED on 5/12/10 at 2345 hours. The patient was triaged at 2353 hours. The patient complained of diffuse abdominal pain with increasingly bloody stools. The patient stated he had history of a hernia. Vital signs were completed and a hemoglobin test was completed with the results of 14.7 g/dL, within normal limits. The patient was assigned an Acuity Level of three. There was no further documentation to show vital signs and reassessments were conducted following the triage assessment.

Review of the physician's ED record for Patient 37, showed the MSE was conducted on 5/13/10 at 1730 hours, 17 hours following the patients arrival and triage in the ED.


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7. On 5/17/10, review of the hospital's discharge policy and procedure titled Department of Emergency Medicine: Nursing Services Unit Structure Standards showed that disposition status will be documented.

On 5/17/10, Patient 35's medical record was reviewed. The medical record showed the patient was a minor, resided in a group home, and was brought in by ambulance. The patient was subsequently transferred to another hospital.

The medical record contained a section titled "ED/Urgent Care Nursing Data Base and Flow Record." In that section there was a subsection where the name of person notified of admission/transfer, their relation to the patient and their phone number was to be recorded. This subsection was left blank. RN F, who was assisting with the record review, acknowledged the absence of transfer notification to the patient's responsible party.


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8. A review of the Department of Emergency Medicine: Nursing services Unit Structure Standards showed that disposition status would be documented.

A review of Patient 52's medical record began on 5/17/10, and showed on page two of the Emergency Medicine Consult form, an area for documenting disposition, date and time. This section of this document was blank.

On the left hand column was a section titled: MDM/Attending/Progress/Procedure Notes. The form directed the physician/psychiatrist to time all notes. Documentation in this section showed patient appeared well, had no medical complaints, and refused an exam. May send to psychiatry. There was no time or date when the note was written.

An interview with RN I was conducted and she stated the form was incomplete and should have disposition, date and time. She stated, "This is our policy."