HospitalInspections.org

Based on the systemic nature of the standard-level deficiencies related to patient rights, the facility staff failed to substantially comply with this condition.

The findings were:

These following standards were cited and show a systemic nature of non-compliance with regards to Patient Rights as follows:

(482.13(c)(2) Tag- 0144)
The information reviewed during the survey provided evidence that the facility failed to prevent self harm of patients in their care for two of two medical records reviewed (MR1 and MR2).

(482.13 Tag-0174)
The information reviewed during the survey provided evidence that the facility failed to ensure four-point leather restraints were removed at the earliest possible time in the Emergency Department (ED) for one of one medical record reviewed (MR2)

(482.13 Tag-0175)
The information reviewed during the survey provided evidence that the facility failed to follow their policy related to monitoring a patient in four-point leather restraints for one of one medical record reviewed (MR2).

Cross Reference:
482.23 Nursing Services
482.25 Emergency Services

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to prevent self harm of suicidal patients in their care for two of two medical records reviewed. (MR1 and MR2).

Findings include:

Review on September 12, 2 018, of the facility's "Crisis Room: Security Metal Detector Use" policy, effective February 21, 2015, revealed "1.0 Purpose: The purpose of this policy is to provide the approved plan to be followed when patients are admitted to the Crisis Room for evaluation. 2.0 Policy: When any patient is admitted to the Crisis Room for the purpose of having an evaluation by the Crisis Caseworker, it will be the responsibility of the Security Officers assigned to the areas to: ... 2.3 All clients/visitors who enter the Crisis Room will be asked by the Mental Health worker Or the Security Office if they have pacemakers, implantable cardioverter/defibrillators or spinal cord stimulators prior to being screened through the [name of metal detector] or with the hand held metal detector. If so, those clients/visitors will not be allowed to pass through the [name of metal detector] but will undergo the hand-held scanner after Security personnel consult with Emergency Room Personnel as to their ability to do so in a safe manner. The "hand held scanner" should not be held near the medical device no longer then is absolutely necessary. If clients/visitors do not have medical devices on or within their person, the following procedure (2.3) will be followed. 2.4 All clients and/or visitors who enter the Crisis Room will be required to pass through the [name of metal detector], if physically able, or be screened. ..."

Review on September 12, 2018, of the facility's "Suicide Risk Assessment and Interventions in a Non-Behavioral Health Setting" policy, last revised August 2017, revealed "Policy: All patients who are admitted for care and services will be assessed for suicide ideation and /or suicide risk factors during initial intake/admission assessment process. In addition, patients who present for evaluation and treatment with a primary diagnosis or complaint of an emotional or behavioral disorder or substance abuse; or display the symptoms of an emotional or behavioral disorder, will be assessed for suicide risk. Based on the level of suicide risk, interventions will be implemented as a means to keep patients form inflicting harm to self or others. Purpose: To identify patients at risk for suicide and provide safety interventions. ... Definitions: ... Suicidal Ideation: Thoughts of harming or killing oneself. Intensity determined by assessing the frequency, duration and intensity of these thoughts; in addition to the presence of a plan. Suicide Attempt: A non-fatal, self-inflicted destructive act with explicit of inferred intent to die. ... Level of Supervision A. Continuous visual surveillance (Level 1) - one patient to one observer (1:1). Observer must maintain 1:1 direct observation and be able to respond to the patient immediately. De-escalation techniques will be used as appropriate. B. Continuous visual surveillance (Level 2). Patient is under direct observation at all times and observer must be able to respond to the patient rapidly. Ratio may be more than 1:1 as long as observer is able to attend to the immediate needs of one patient without sacrificing surveillance and attendance to the immediate needs of another patient(s). Observer must have direct line of sight of patient. If de-escalation techniques are ineffective, patient will be escalated to Activity Level 1. C. Close observation (Level 3): Patient may not be left alone without support person (may be reliable family/friend). Observation is required by hospital staff at intervals at a maximum of 15-minute intervals. Supportive family/friend must receive education from staff on expected responsibilities and be willing to sign a contract to stay with the patient at all times or know and agree to communicate with/seek staff assistance if chooses to leave for any concerns. In absence of reliable support person, patient will be escalated to Activity Level 2. D. Intermittent observation (Level 4): Observation at a maximum of 30-minute intervals by clinical staff. E. General observation (Level 5): Routine check by clinical staff at a maximum of one-hour intervals. ..."

Review on September 12, 2018, of the facility's "Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting" form, last reviewed April 12, 2018, revealed "Level 1 Definition Requires immediate life-saving intervention. Immediate danger to self or others. Observed Violent Behavior Possession of weapon Self-Destructive act that resulted in physical harm Reported Verbal commands to do harm to self or others (command hallucinations) violent/self-destructive behavior Behavior that has resulted in harm to self or others, including actual suicide attempt Interventions Continuous visual surveillance 1:1 ratio: direct observation by staff at all times. must be able to respond to patient immediately. Use de-escalation techniques. Assess for appropriateness for restraint or seclusion per policy. Obtain Mental Health Professional evaluation. Level 2 High-risk situation Risk of danger to self or others and/or Severe behavioral disturbance Observed Extreme agitation Physically/verbally/aggressive Uncooperative hallucinations/delusions/paranoia distorted perception of reality May or has require(d) restraint/seclusion Words or behavior reflect high risk of elopement (pacing, hovering near doorway) signs of severe depression (Activities of Daily Living impacted) Reported threat to harm self or others Suicidal ideation (thoughts of suicide) with or without a plan acute drug or alcohol intoxication with history of suicide attempt or ideation Psychotic symptoms: Hallucinations, delusions, paranoid ideas, thought disorder, unusual or agitated behavior Overwhelming symptoms of depression Interventions Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation. ..."

Review on September 12, 2018, of the facility's "Suicide Precautions" policy, last revised November 2017, revealed "Purpose: To outline a mechanism for observation and protection of patients who are assessed to be at for suicide, or have expressed suicidal ideations. Policy: 1. A physician's order must be obtained for suicide precautions and psychiatric consult obtained. 2. Suicide precautions must be re-ordered daily. 3. A patient monitor is assigned until the patient is either transferred to an appropriate facility or is determined to be no longer at risk and discontinued. 4. The nurse will inform the patient that he/she is being placed on suicide precautions and explain the rational. 5. The patient on suicide precautions should be assigned the bed near the door in a semi-private room. 6. An environmental safety check of the patient's room will be performed. 7. Patient belongings will be checked closely and all potentially harmful items will be removed, labeled and secured in the designated area on each department. ... 13. The patient monitor is to be seated at the foot of the patient's bed (beyond arms length but in direct proximity of the patient). 10. (sic) The patient monitor will report any potentially unsafe behaviors to the assigned nurse. ..."

1) Review of MR1 on September 11, 2018, revealed this patient was admitted to the ED on August 11, 2018, for evaluation and treatment of suicidal ideations and major depression with a history of cutting self. The ED physician ordered 1:1 sitter at the bedside for constant observation at all times on August 11, 2018, on admission to the ED.

Review on September 11, 2018, of MR1's Suicide Risk/Behavioral Disorder Assessment dated August 11, 2018, at 2:15 PM revealed the facility assessed this patient as a Level 1 suicide risk requiring continuous visual surveillance 1:1 ratio: Direct observation by staff at all times. Must be able to respond to patient immediately. Use de-escalation techniques. Assess for appropriateness for restraint or seclusion per policy. Obtain Mental Health Professional evaluation.

Review of MR1 on September 11, 2018, revealed nursing documentation dated August 11, 2018, at 3:00 PM that MR1 was wanded (hand held metal detector) by security. There was no documentation security identified any concealed metal items or safety hazards.

Review of MR1 on September 11, 2018, revealed nursing documentation dated August 11, 2018, at 3:20 PM there was no sitter at the bedside because no sitter available.

Review of MR1 on September 11, 2018, at 4:45 PM revealed nursing documentation this patient had multiple open lacerations on the arms and front of the neck. MR1's incision/wound charting revealed there were six open lacerations on the arms and front of the neck requiring sutures and 11 lacerations on the arms and front of the neck requiring steri-strips to close the wounds.

Interview with EMP1, EMP3 and EMP7 September 11, 2018, at approximately 9:15 AM confirmed MR1 was admitted to the ED for evaluation and treatment of suicidal ideations and major depression; the ED physician ordered 1:1 sitter at the bedside for constant observation at all times; MR1 was wanded by security; that no concealed metal items or safety hazards were found and MR1's nursing documentation revealed there was no sitter at the bedside because no sitter available. EMP1, EMP3 and EMP7 confirmed MR1's nursing documentation this patient had multiple open lacerations on the arms and front of the neck and this patient's incision/wound charting revealed there were six open lacerations on the arms and front of the neck requiring sutures and 11 lacerations on the arms and front of the neck requiring steri-strips to close the wounds.

2) Review of MR2 on September 13, 2018, revealed this patient was admitted to the ED on July 29, 2018, at 1:18 AM for evaluation and treatment of a suicidal attempt.

Review on September 13, 2018, of MR2's admission Suicide Risk/Behavioral Disorder Assessment dated July 29, 2018, revealed the facility assessed this patient as a Level 1 suicide risk requiring continuous visual surveillance 1:1 ratio: Direct observation by staff at all times. must be able to respond to patient immediately. Use de-escalation techniques. Assess for appropriateness for restraint or seclusion per policy. Obtain Mental Health Professional evaluation. The ED physician ordered Continuous visual surveillance 1:1 direct observation on this patient.

Review on September 13, 2018, of MR2's Physician's Restraint/Seclusion Orders Violent - Self Destructive order sheet dated July 29, 2018, at 1:10 AM revealed a physician order instructing nursing staff to apply four-point leather restraints. ED nursing staff applied leather restraints to MR2's both wrists and both ankles.

Review of MR2 on September 13, 2018, revealed nursing documentation dated July 29, 2018, at 1:30 AM this patient was being obstructive to self and others by kicking and screaming to staff, thrushing (sic) around in bed, and trying to bite staff. At 1:35 AM on July 29, 2108, nursing documented this patient was able to strangle self with the gown strings. Oxygen was applied to the patient; the patient was hypoxic (inadequate oxygenation of the blood related to suffocation) and the doctor was made aware.

Review of MR2 on September 13, 2018, revealed physician documentation that MR2 was cyanotic (blue discoloration of the skin due to having low oxygen in the blood) and initially not responsive. MR2 was bagged for a few seconds and became awake.

Review of MR2 on September 13, 2018, revealed no documentation this patient was provided a sitter for 1:1 direct observation.

Review of MR2 on September 13, 2018, revealed nursing documentation dated July 29, 2018, at 9:52 AM, 11:03 AM and 3:00 PM that this patient was ordered Level 1 (Continuous visual surveillance). Nursing documentation revealed there was no sitter at the bedside due to the lack of staffing.

Interview with EMP1, EMP3 and EMP7 September 13, 2018, at approximately 9:20 AM confirmed MR2 was admitted to the ED for evaluation and treatment of a suicidal attempt: the facility assessed this patient as a Level 1 suicide risk requiring continuous visual surveillance 1:1 ratio and that MR2 was placed in four-point leather restraints. EMP1, EMP3 and EMP7 confirmed nursing documented this patient was able to strangle self with the gown strings and MR2 became hypoxic requiring oxygen administration. EMP1 and EMP3 confirmed there was no documentation this patient was provided a sitter for 1:1 direct observation and that nursing documented there was no sitter at the bedside due to the lack of staffing.

Based on a review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure four-point leather restraints were removed at the earliest possible time in the Emergency Department (ED) for one of one medical record reviewed (MR2).

Findings include:

Prevention/Alternatives and Use of Restraints/Protective Devices policy, last revised December 21, 2016. "Philosophy: The patient has the right to be free from restraints of any form that are not absolutely medically or behaviorally necessary. Our approach to restraint will protect the patient's health and safety and maintain the patient's dignity. ... Definitions: Restraint: Includes whether a physical restraint or a drug that is being used as a restraint. 1. A physical restraint is any manual method or physical or mechanical device, material or equipment that immobilizes or reduces the ability of a patient to freely move his or her arms, legs, body, or head. Policy: 1. Restraints must never be used as a means of coercion, discipline, convenience or retaliation by the staff. 2. A restraint may be used to ensure the patient's immediate physical safety even if the patient is not violent or self-destructive. ... 6. A restraint must be discontinued at the earliest possible time. ... ."

The facility utilizes a Restraint Flow Sheet, dated December 2015, for documentation. The Restraint Flow Sheet includes the following behaviors: ... "Patient State: 1. Resting 2. Restless/Agitated 3. Spitting/biting 4. Verbally abusive 5. Fighting 6. Trying to leave. ... Violent/Self-Destructive Behavior Restraints or Seclusion: ... Nurses initials every hour and then checks every 15 minutes in the appropriate box. ... ."

Review of MR2 revealed a physician order dated July 29, 2018, at 1:10 AM, instructing nursing staff to apply four-point leather restraints to the patient's wrists and ankles. Nursing staff applied four-point restraints on July 29, 2018, at 1:10 AM.

Review of MR2 Restraint Flow Sheet dated July 29, 2018, revealed nursing documented this patient's behavior as resting at 3:00 AM, at 4:00 AM and at 5:00 AM. There was no nursing documentation in MR2 indicating the need for continuing restraints.

Interview with EMP1 and EMP3 on September 12, 2018, at approximately 1:00 PM confirmed MR2's physician order for four-point leather restraints and nursing staff applied MR2's four-point restraints on July 29, 2018, at 1:10 AM. EMP1 and EMP3 confirmed nursing documented MR2's behavior as resting at 3:00 AM, at 4:00 AM and at 5:00 AM. EMP3 confirmed there was no documentation in MR2 indicating nursing staff begun removing MR2's four-point restraints at the earliest possible time.

Cross reference
482.55 Emergency Services

Based on a review of facility documents, medical record review (MR) and staff interview (EMP), it was determined the facility failed to follow their policy related to monitoring a patient in four-point leather restraints for one of one medical record reviewed (MR2).

Findings include:

Restraint Flow Sheet, dated December 2015. "... Patient State: 1. Resting 2. Restless/Agitated 3. Spitting/biting 4. Verbally abusive 5. Fighting 6. Trying to leave. ... Violent/self-Destructive Behavior Restraints or Seclusion: Visual check of patient including circulation, sensation and movement, patient state, and skin integrity, and psychological distress are checked every 15 minutes and PRN (as needed). Nutritional, hydration, repositioning, elimination needs, and range of motion with release and message (sic) as needed are provided every 2 hours and PRN. Continued need for restraints is reevaluated every 2 hours. Nurses initials every hour and then checks every 15 minutes in the appropriate box. ... ."

Review of MR2 revealed a physician order dated July 29, 2017, at 1:10 AM instructing nursing staff to apply four-point leather restraints to the patient's wrists and ankles. Nursing staff applied four-point restraints on July 29, 2018, at 1:10 AM.

Review of MR2 Restraint Flow Sheet dated July 29, 2018, lacked documentation that nursing staff visually checked this patient's circulation, sensation and movement, skin integrity and psychological distress at 2:15 AM, 2:30 AM, 2:45 AM, 3:15 AM, 3:30 AM, 3:45 AM, 4:15 AM, 4:30 AM and at 4:45 AM.

Interview with EMP1 and EMP3 on September 12, 2018, at approximately 1:30 PM confirmed the physician order instructing nursing staff to apply four-point restraints on July 29, 2018, at 1:10 AM. EMP1 and EMP3 confirmed there was no documentation on MR2 Restraint Flow Sheet indicating nursing staff visually checked this patient's circulation, sensation and movement, skin integrity and psychological distress at 2:15 AM, 2:30 AM, 2:45 AM, 3:15 AM, 3:30 AM, 3:45 AM, 4:15 AM, 4:30 AM and at 4:45 AM.

Cross reference
482.55 Emergency Services

Based on the systemic nature of the standard-level deficiencies related to nursing services, the facility staff failed to substantially comply with this condition.

The findings were:

These following standards were cited and show a systemic nature of non-compliance with regards to nursing services as follows:

(482.23 Tag-0386)
The information reviewed during the survey provided evidence that the facility failed to ensure Nursing Administration provided oversight of clinical services related to nurse staffing.

(482.23 Tag-0392)
The information reviewed during the survey provided evidence that the facility failed to schedule sufficient number of Registered Nurses and/or ancillary staff on the nursing units for 81 of 148 shifts reviewed.

(482.23 Tag-0393)
The information reviewed during the survey provided evidence that the facility failed to provide registered nurse supervision for licensed practical nurses scheduled on the Six center/south/north nursing unit for seven out of seven assignment sheets reviewed.

(482.23 Tag-0405)
The information reviewed during the survey provided evidence that the facility failed to administer medications on time for two of three medical records reviewed (MR12 and MR13).

Cross Reference:
482.13 Patient Rights
482.25 Emergency Services

Based on a review of facility documents and staff interview (EMP), it was determined the Chief Nursing Officer and the Assistant Chief Nursing Officer failed to provide oversight of the Wilkes-Barre General Hospital overall clinical care functions including staffing and supervision of staff.

Findings include:

1) Review on September 12, 2018, of the facility's "Chief Nursing Officer Administration Wilkes-Barre General Hospital," last revised May 2013, revealed "...Position Purpose A senior administrative member of [name of health care system], Hospital Division, who plans, organizes, directs and controls the overall clinical care functions. Communicate, support and implement, organizational strategic plan and vision to members of the clinical departments. ... General Duties 1 All applicable duties as assigned 2 Participate in Senior Management decision making and strategic planning, including setting financial and organizational goals 3 Responsible for coordination of operations of Patient Care/Clinical Care service functions, specifically in the areas of personnel assignments, staffing requirements and staff development programs 4 Responsible for the selections, training, evaluation and development of Clinical Services personnel, including Administrative Directors 5 Provide strategic planning leadership for all Clinical Services Departments 6 Collaborate with other Senior Managers in the development of the hospital budget 7 Plan and supervise the preparation and administration of department budgets ...13 Participate in the development of hospital wide patient care programs, policies and procedures that describe how the needs of patient or patent [sic] populations are assessed, evaluated and met ... 16 Formulate objectives for the Division, and establishes budgetary guidelines by which goals can be achieved 17 Develop goals for the Division and establish budgetary guidelines by which goals can be achieved ..."

Review on September 12, 2018, of the facility's "Assistant Chief Nursing Officer Clinical Services Wilkes-Barre General Hospital," last revised May 2013, revealed "... Position Purpose This senior Clinical Services leadership position is responsible for planning, directing, and coordinating Clinical Services. Major responsibilities include ensuring the quality of services provided. ...General Duties 1 All applicable duties as assigned 2 Develop operational and capital budgets; monitor for budget variances; ensure compliance with fiscal goals ... 5 Develop work methods to reduce costs/manpower and increase productivity 6 Develop strategic plans around human resource needs and management; analyze pertinent factors effecting recruitment and retention; provide recommentdations and implement solutions as needed ... 15 Coordinate recruitment and retention efforts ... 18 Ensure that directors/managers maintain compliance with budget ... 20 Provide oversight for service operations including staff, equipment and supplies, staff education and training ... 22 Promote culture of safety for patients and staff ..."

Review on September 11, 2018, of the facility's Six center/south/north nursing unit patient staffing assignment sheets revealed seven out of seven assignment sheets revealed a licensed practical nurse was working and registered nurse coverage was not assigned.

Review on September 11, 2018, of approximately 148 shift increments which included assignment sheets and staffing grids for the nursing units, it was noted that 81 of the 148 shifts did not meet their adopted staffing grid for RN's and/or nurse's aides or unit secretaries.

Interview on September 12, 2018, at approximately 1:00 PM with EMP1 confirmed the Chief Nursing Officer has overall responsibilities for the facility's clinical care functions.

Cross reference:
482.13 Tag A-0115 Patient Rights
482.55 Tag A1100 Emergency Services

Based on review of facility documents, patient (PT) interviews and staff (EMP) interviews, it was determined the facility failed to schedule sufficient number of Registered Nurses and/or ancillary staff on the nursing units for 81 of 148 shifts.

Findings include:

Review on September 11, 2018, of the facility document, "Staffing Guidelines," no date listed, revealed "The following pages contain the guidelines used for determining the recommended number of staff needed for patient coverage for the individual patient care units. ...If the numbers of staff available does not meet the minimum level required, measures are taken to address the situation and ensure that patient care is not compromised. ..."

A request was made on September 10-11, 2018 for a policy and procedure related to nursing unit staffing. None was provided.

Interview on September 11, 2018, at approximately 2:00 PM with EMP1 revealed the facility did not have a policy related to nursing unit staffing.

Following review of 148 shift increments which included assignment sheets and staffing grids for the nursing units, it was noted that 81 of the 148 shifts did not meet their adopted staffing grid for RNs and/or nurse's aides or unit secretaries.

Interviews were conducted with EMP1, EMP3, EMP4, EMP6, EMP40 confirmed assignment sheets and staffing grids for 81 of the 148 shifts did not meet their adopted staffing grid for RNs and/or nurse's aides or unit secretaries.

Review of the overtime by position for June, July, August 2018 revealed RN 15434.88 hours; Agency RN 3025.75 hours; RN Weekender/Alternate RN Rate 286.3 hours; Nursing Assistant 4781.97 hours; Unit Secretary 2171.9 hours.

Interview on September 10, 2018, with EMP9 revealed they feel the patients are sicker now when admitted to the hospital than they were years ago therefore, the acuity of these patients is higher ...Facility doesn't follow staffing grids. They stated there aren't enough aides or secretaries to go around. The aide may start the shift on telemetry, but get pulled to the ED to help out.

Interview on September 10, 2018, at approximately 5:30 PM, with EMP43 revealed EMP43 stated the staff does not have enough help. EMP43 stated an Medical Surgical Intensive Care Unity (MSICU) RN is pulled from their patient assignment for any trauma level one's called in the emergency department. EMP43 explained a nurse could be gone for up to two hours for a trauma and it is possible for multiple traumas to occur at once, which leaves the remaining MSICU nurses to cover 3-4 total patients. EMP43 explained the nurses never get breaks, there is a delay in care/treatments/medications for patients due to the staffing. EMP43 explained there is not enough staff to turn patients or care for patients properly. EMP43 stated the staffing was unsafe for patients and staff. EMP43 explained the MSICU does not have an aide on second shift and they do not always have a secretary. EMP43 explained when a patient needs to be transferred to a tertiary facility and is highly unstable nurses are often pulled away from the patient to complete the administrative paperwork to prepare for the transfer. EMP43 stated the lack of ancillary staff leaves patients at risk. EMP43 further explained nurses are also taken away from their patient assignment when aides or sitters are necessary for suicidal patients. EMP43 explained the nurses have been told by nursing supervisors to relieve the sitters for breaks and lunches. EMP43 stated the patients on our unit are very sick and this is not fair to them.

Interview on September 10, 2018, at approximately 7:25 PM with EMP51 revealed EMP51 had also been asked to take three patients but refused. EMP51 explained they felt three CVICU patients was not a safe assignment and would not accept that assignment. EMP51 stated there are no aides or secretaries in the evenings and that makes it difficult to take care of the patients especially during an emergency. EMP51 explained often when they need emergent blood for a patient there is no staff to retrieve the blood. EMP51 explained on multiple occasions they had to call the nursing supervisor to retrieve the blood. EMP51 explained it is frustrating and they do their best to take care of the patients.

Interview on September 10, 2018, with EMP17 revealed they are per diem, but work enough hours to be full time because there is so much overtime. They felt every shift is short staffed with aides. Weekends are worse. They revealed they may start their shift on telemetry, but end up working as a monitor tech in the ED in crisis. They spent the last week in the ED working crisis because there were not enough monitor techs.

Interview on September 10, 2018, at approximately 7:35 PM with PT2 and PT2's family revealed they had been in the hospital for about one week. PT2 stated they were admitted to a medical/surgical floor before they was transferred to the Cardiovascular Intensive Care Unit (CVICU). They felt the nurses were too busy to take care of them on that floor. PT2's husband stated it took the staff along time to answer the call bell and the patient had an accident because of that.

Interview on September 10, 2018, with EMP21 stated weekends are worse. Everyone calls off. They stated it's difficult to get your work done on time when there isn't enough ancillary help. This is the worst they have ever seen it. Morale is down. EMP21 stated they might discharge two patients in a shift and then admit two more and admissions are a lot of work.

A request was made for data related to open RN positions and ancillary clinical staff on September 10 and 12, 2018. No data was provided for open ancillary clinical staff positions.

Interview on September 12, 2018, at approximately 10:30 AM with EMP58 revealed the facility currently has 91 Registered Nurse positions open. EMP58 revealed the facility currently has 29 Passport nurses on staff and 12 travel or agency nurses on staff.

A request was made on September 10 and 14, 2018, for the Staffing Benchmarks utilized by the facility. None were provided.

Interview on September 14, 2018, with EMP1 and EMP3 revealed there were no Staffing Benchmarks to provide.

Based on review of facility documents and staff interview (EMP), it was determined the facility failed to provide registered nurse supervision for licensed practical nurses scheduled on the Six center/south/north nursing unit for seven out of seven assignment sheets reviewed.

Findings include:

Review on September 11, 2018, of the facility policy, "Assignments," dated effective November 2017, revealed "Purpose: To establish guidelines for making assignments of patients to nursing personnel. Policy: 1. All patient assignments are made by the Clinical Director, Clinical Leader, or RN designee. ...7. Graduate Nurses and Licensed Practical Nurses are sub-assigned to Registered Nurses. ..."

Review on September 11, 2018, of the facility policy, "Intershift/Bedside Report," dated effective December 2017, revealed "Policy: To define the guidelines for intershift/bedside report for the telemetry unit. Procedure: . ...H. The assignment sheet will be completed and posted on the unit in the same designated area. It will be the responsibility of the charge nurse to assure the completion of all of the checks listed on the assignment sheet. It will include the following information: . ...7. RN to LPN coverage. ..."

Review on September 12, 2018, of the facility, "Registered Nurse/Graduate Nurse Telemetry Clinical Services Position Description," dated revised September 2014, revealed "The Telemetry Registered Nurse/Graduate Nurse consistently performs his/her duties demonstrating an understanding of the essential job functions as reflected in the Telemetry Registered Nurse/Graduate Nurse job description, department and hospital policies, and regulatory guidelines. Provide direct professional nursing care for assigned patients while maintaining a safe patient care environment. Responsible for directing and coordinating all nursing care based on established clinical nursing practices. ...General Duties. ...21 Demonstrate leadership skills/charge responsibilities-covers LPN's and NA's, assigns patient care appropriately, assigns patient beds appropriately. ... "

Review on September 12, 2018, of the facility, "Licensed Practical Nurse/Graduate Practical Nurse Telemetry Clinical Services Position Description," dated revised May 2013, revealed "The Telemetry Licensed Practical /Graduate Practical Nurse consistently performs his/her duties demonstrating an understanding of the essential job functions as reflected in the Telemetry Licensed Practical Nurse/Graduate Practical Nurse job description, department and hospital policies, and regulatory guidelines. Utilize the nursing process to provide quality patient care under the supervision of the registered nurse. ..."

Review on September 11, 2018, of the facility's Six center/south/north nursing unit patient staffing assignment sheets revealed seven out of seven assignment sheets revealed a licensed practical nurse was working and registered nurse coverage was not assigned.

Interview on September 11, 2018, with EMP6 confirmed seven out of seven patient assignment sheets on Six center/south/north revealed a licensed practical nurse was working and a registered nurse was not assigned to supervise.

Based on review of facility documents, medical records (MR), and staff interviews (EMP), it was determined the facility failed to administer medications on time for two of three medical records reviewed (MR12 and MR13).

Review on September 14, 2018, of the facility's "13-09-H Administration of Drugs Policy - Medication Administration Times," last reviewed July 27, 2018, revealed "... 2. Procedure 2.1 When transcribing or entering new or recopied medication orders, the exact corresponding schedule time is to be entered in the scheduled time as follows: Daily 0800 BID 0900 2100 ...Every 8H 0800 1600 2400 Every 12H 0900 2100 ..."

Review on September 14, 2018, of the facility policy, "Medication Administration General Rules," last reviewed July 2018, revealed "... Purpose: The purpose of this policy is to establish general guidelines for the administration of medications. ... General Rules For Medication Administration: ... 12. Medications should be given on time; however, they may be administered one (1) hour before or one (1) hour after the scheduled medication time. Note: If deemed appropriate to hold or stagger a medication to adjust for dosing intervals, or to accommodate a clinical reason, the nurse will enter a comment to explain the reason for the adjustment. ..."

Review on September 14, 2018, of MR12 revealed MR12 was admitted to the facility on April 6, 2018, for treatment of left lower quadrant pain, an abdominal abscess, and a fall at home. There was documentation of an order for Zosyn (an antibiotic) 3.375 gm (grams) IV (intravenous) Piggyback every 8 hours (0800 1600 2400). There was nursing documentation the medication was administered late at 1712 instead of 1600 on April 10, 2018. There was no documentation of an explanation.


Interview on September 14, 2018, at approximately 10:30 AM with EMP1 confirmed there was documentation in MR12 the medication Zosyn was administered late on April 10, 2018. EMP1 confirmed there was no documentation to explain the late administration.

Review on September 14, 2018, of MR13 revealed MR13 was admitted to the facility on April 6, 2018, for treatment of chronic kidney disease and ambulatory dysfunction. There was documentation of an order for Allopurinol (a medication to treat elevated uric acid levels) 100 mg (milligrams) 1 tablet by mouth daily (0800). There was nursing documentation the 0800 dose of medication was administered at 1040 on April 11, 2018. There was no documentation of an explanation.

Interview on September 14, 2018, at approximately 10:40 AM with EMP1 confirmed there was documentation in MR13 the medication Allopurinol was administered late on April 11, 2018. EMP1 confirmed there was no documentation to explain the late administration.

Based on the systemic nature of the standard-level deficiencies related to emergency services, the facility staff failed to substantially comply with this condition.

The findings were:

These following standards were cited and show a systemic nature of non-compliance with regards to emergency services as follows:

(482.55 Tag-1103)
The information reviewed during the survey provided evidence that the facility failed to coordinate and communicate with other hospital departments by failing to have adequate numbers of Security staff to check closely and remove all potentially harmful items from suicidal patient's belongings and by failing to have adequate numbers of registered nurses trained to respond to Trauma Alert Activation in the ED without pulling nurses from other units.

(482.55 Tag-1104)
The information reviewed during the survey provided evidence that the facility failed to ensure a patient presenting to the Emergency Department (ED) was assessed for concealed metal items for one of one medical record reviewed (MR1).

(482.55 Tag-1112)
The information reviewed during the survey provided evidence that the facility failed to provide qualified staff in adequate numbers to prevent suicidal patients from self-harm for two of two medical records reviewed (MR1 and MR2).

Cross Reference:
482.13 Patient Rights
482.23 Nursing Services

Based on review of facility documents and staff interview (EMP), it was determined the facility to coordinate and communicate with other hospital departments by failing to have adequate numbers of Security staff to provide safety checks on suicidal patients and by failing to have adequate numbers of registered nurses trained to respond to Trauma Alert Activation in the ED without pulling nurses from other units.

Findings include:

Review on September 10, 2018, of the facility's "Trauma Alert Activation" policy, last reviewed January 2018, revealed "Purpose: The purpose of this policy is to activate a prescribed group of trained personnel to respond within the hospital and standardize the activation of the trauma team when a trauma patient, who meets the criteria described in this policy, arrives at Wilkes-Bare General Hospital. Scope: This policy applies to any member of the trauma team but is most likely to be initiated by the Emergency Department (ED) attending physician or nurse. Definitions: Trauma Alert (Level I, II, and III): For all patients greater than fourteen (14) years of age. ... Pediatric Trauma Alert: For all patients fourteen (14) years of age or less Trauma Alert - OB: For all patients greater than or equal to 20 weeks gestation Resuscitation: This intense period of patient assessment and medical care to save life or limb Trauma Team: A group of health care professionals organized to provide care and monitor the trauma patient in coordinated and timely fashion Trauma Resuscitation Area: A space used for trauma resuscitation. It must be of adequate size to accommodate for full trauma resuscitation, and equipment. Trauma Resuscitation Team: Major trauma resuscitations require a multidisciplinary team of health care providers who work in synergy to rapidly assess and treat the patient. The trauma attending or appropriate designee must lead the team. ... Procedure: The Trauma Alert response will be determined prior, if at all possible, to the patient's arrival by the Emergency Department physician and /or ED RN or Trauma surgeon. All level I and II trauma alerts will be taken to the trauma resuscitation rooms upon pre-hospital arrival. The Emergency Department physician and /or ED RN or the Trauma Surgeon will initiate a Trauma Alert prior to the arrival of the patient if prior information is available. If no prior notification is obtained, then the Trauma Alert will be called on the patient's arrival in the Emergency Department. The ED physician will give medical commend to ALS/BLS units. The designated Trauma Nurse will notify the switchboard of the classification of Trauma Alert and the estimated time of arrival. ... The ED nurse at the direction of the ED physician activates Trauma Alert Level II. The switchboard will notify the response team to be present upon patient arrival. Trauma Team that will respond will include the following: ... 3. Designated emergency Department trauma nurse ... The ED nurse at the direction of the ED physician activates Trauma Alert Level III. The Trauma surgeon will be paged by the ED physician or Nurse. 1. Emergency Department physician 2. Trauma Surgeon 3. Designated emergency Department trauma nurse. ..."

Review on September 11, 2018, of the facility's "Staffing the Emergency Department" policy, effective June 2015, revealed "Purpose: The purpose of this policy is to explain the methodology for properly staffing the Emergency Department. Policy: Patients presenting to the emergency department are seen as quickly as possible. Staffing must be appropriate for this to occur. ... Procedure: ... 2. Scheduling a. In accordance with the CBA [Collective Bargaining Agreement] and Hospital Policy, emergency Department Leadership issues a six-week schedule in the electronic scheduling program with the maximum number of staff members in each title that would be required at a given hour of the day. ..."

Interview with EMP29, EMP30 and EMP31 on September 10, 2018, revealed there is not always a Flow/Trauma Nurse always assigned to cover this position. These employees revealed when a trauma patient presents to the ED, and there is no Flow/Trauma Nurse coverage, a RN is pulled from their patient assignment to cover the trauma.

Review on September 11, 2018, of the ED staffing sheets for August 1, 4, 8, 12, 13, 14, 17, 19, 20, 21, 22, 25, 26, 27 and 28, 2018, revealed no designated Flow/Trauma Nurse coverage.

Review on September 11, 2018, of the ED trauma list for August 2018, revealed the following trauma patients presented to the ED:
August 8, 2018: 2 - Level II trauma patients
August 13, 2018: 1 - Level 2 trauma patients
August 20, 2018: 1 - Level I trauma patient
August 21, 2018: 1 - Level I trauma patients
August 25, 2018: 1 - Level I trauma patient; 3 - Level II trauma patients and 1 - Level III trauma patient
August 26, 2018: 1 - Level I trauma patient and 1 - Level III trauma patient
August 29, 2018: 1 - Level I trauma patient

Interview with EMP3 and EMP7 on September 11, 2018, at approximately 10:45 AM confirmed there was no designated Flow/Trauma Nurse coverage on August 1, 4, 8, 12, 13, 14, 17, 19, 20, 21, 22, 25, 26, 27 and 28, 2018. EMP7 confirmed when trauma patients present to the ED and there is no designated Flow/Trauma Nurse coverage, a RN is pulled from their assignment to cover the trauma.

Review on September 11,2 018, of the ED staffing sheets for September 4, 5, 6, 7 and 9, 2018, revealed no designated Flow/Trauma Nurse coverage.

Review on September 11, 2018, of the ED trauma list for September 2018, revealed the following trauma patients presented to the ED:
September 4, 2018: 3 - Level I trauma patients and 1 - Level II trauma patient
September 5, 2018: 1 - Level 2 trauma patients
September 6, 2018: 1 - Level I trauma patients; 2 - Level II trauma patients and 1 - Level III trauma patient
September 7, 2018: 2 - Level II trauma patients

Interview with EMP3 and EMP7 on September 11, 2018, at approximately 12:00 PM confirmed there was no designated Flow/Trauma Nurse coverage on September 4, 5, 6, 7 and 9, 2018. EMP7 confirmed when trauma patients present to the ED and there is no designated Flow/Trauma Nurse coverage, a RN is pulled from their assignment to cover the trauma.
Review on September 10, 2018, of the facility provided the "Emergency Department Staffing Grid " dated June 16, 2018, revealed the required staffing at 7 AM is 10 Registered Nurses (RN's), 1 RN for Crisis, 2 Techs; 1 Nurse Assistant (NA) and 1 Unit Secretary (US); at 9 AM the required staffing is 12 RN's, 1 RN for Crisis, 2 Techs; 2 NA's and 1 US; at 11 AM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 3 PM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 7 PM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 11 PM the required staffing is 14 RN's, 1 RN for Crisis, 2 Techs; 2 NA's and 1 US; and at 3 AM the required staffing is 8 RN's, 1 RN for Crisis, 2 Techs; 1 NA and 1 US."

Interview with EMP3 on September 10, 2018, at approximately 8:00 PM revealed the time from 11:00 AM to 7:00 PM are the busiest times with more patient visits in the ED. EMP3 revealed staffing numbers are increased during this time due to the increase in patient visits.

Interview with EMP29, EMP30, EMP31, EMP32, EMP33, EMP34, EMP35, EMP36, EMP37 and EMP38 on September 10, 2018, revealed there is inadequate staffing of Registered Nurses (RN), Techs, Nursing Assistants (NA's) and Unit Secretary's (US) in the ED.

On September 10, 2018, a random sample of the ED staffing sheets for August 2018 and September 2018 were selected for review.

Review on September 11, 2018, of the staffing sheets for August 1, 3, 4, 5, 6, 10, 11, 12, 20, 21, 25, 27, and 31, 2018, revealed the facility did not meet the required staffing per the staffing grid for the ED.

Interview with EMP3 on September 11, 2018, at approximately 10:15 AM confirmed the facility did not meet the required staffing for RN's, Techs, NA's and Unit Secretary's per the established staffing grid in the ED for August 1, 3, 4, 5, 6, 10, 11, 12, 20, 21, 25, 27, and 31, 2018.

Review on September 11, 2018, of the staffing sheets for September 2, 4, 5, 6, and 9, 2018, revealed the facility did not meet the required staffing per the staffing grid for the ED.

Interview with EMP3 on September 11, 2018, at approximately 12:00 PM confirmed the facility did not meet the required staffing for RN's, Techs, NA's and Unit Secretary's per the established staffing grid in the ED for September 2, 4, 5, 6, and 9, 2018.

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to follow their policy related to metal detector use for patients presenting to the Emergency Department Crisis (ED) for one of one medical record reviewed (MR1).

Findings include:

Review on September 12, 2018, of the facility provided Metal Detector user manual revealed "... The [name of metal detector] with both audible and silent vibrating alarms offers outstanding performance as well as operating features not found in any other hand-held detector, with state of the art circuitry that allows instant operation, which provides the optimum setting with no operator adjustment. With full 360 (degree) plus detection coverage - even at its tip - the [name of metal detector] is very effective in easily detecting even the smallest of metallic objects. ... Recommended Body Scanning Procedure The illustrations indicate scanning beginning at the head then going to one arm and leg, then the other arms and leg and finally down the trunk on the front and back of the body. ..."

Review on September 12, 2 018, of the facility's "Crisis Room: Security Metal Detector Use" policy, effective February 21, 2015, revealed "1.0 Purpose: The purpose of this policy is to provide the approved plan to be followed when patients are admitted to the Crisis Room for evaluation. 2.0 Policy: When any patient is admitted to the Crisis Room for the purpose of having an evaluation by the Crisis Caseworker, it will be the responsibility of the Security Officers assigned to the areas to: ... 2.3 All clients/visitors who enter the Crisis Room will be asked by the Mental Health worker Or the Security Office if they have pacemakers, implantable cardioverter/defibrillators or spinal cord stimulators prior to being screened through the [name of metal detector] or with the hand held metal detector. If so, those clients/visitors will not be allowed to pass through the [name of metal detector] but will undergo the hand-held scanner after Security personnel consult with Emergency Room Personnel as to their ability to do so in a safe manner. The "hand held scanner" should not be held near the medical device no longer then is absolutely necessary. If clients/visitors do not have medical devices on or within their person, the following procedure (2.3) will be followed. 2.4 All clients and/or visitors who enter the Crisis Room will be required to pass through the [name of metal detector], if physically able, or be screened. ..."

Interview with EMP60 and EMP61 on September 12, 2018, at approximately 9:45 AM revealed the facility purchased a [name of metal detector] approximately seven years ago and this metal detector was put into storage and never utilized in the Emergency Department due to not having enough staff in the security department to use and man this piece of equipment.

Interview with EMP60 and EMP61 on September 12, 2018, at approximately 9:50 AM revealed this [name of metal detector] scans the persons entire body from the head to the feet.

Review of MR1 on September 12, 2018, revealed this patient was admitted to the ED on August 11, 2018, for evaluation and treatment of suicidal ideations and major depression with a history of cutting self.

Review of MR1 on September 12, 2018, revealed nursing documentation dated August 11, 2018, at 3:00 PM that MR1 was wanded (hand held metal detector) by security. There was no documentation security identified any concealed metal items or safety hazards.

Review of MR1 on September 12, 2018, at 4:45 PM revealed nursing documentation this patient had multiple open lacerations on the arms and front of the neck. MR1's incision/wound charting revealed there were six open lacerations on the arms and front of the neck requiring sutures and 11 lacerations on the arms and front of the neck requiring steri-strips to close the wounds.

Review of MR1 on September 12, 2018, revealed nursing documentation dated August 11, 2018, at 8:30 PM a call was received from a friend of MR1's indicating MR1 had a razor blade in the mouth.

Review of MR1 on September 12, 2018, revealed nursing documentation this patient was cooperative with a mouth search; handed ED staff a razor blade from the mouth and that MR1 indicated this patient keeps it there all the time.

Interview with EMP1, EMP3 and EMP7 September 12, 2018, at approximately 10:15 AM confirmed MR1 was wanded by security and no concealed metal items or safety hazards were found. EMP1, EMP3 and EMP7 confirmed that MR1 produced a razor blade they had in their mouth.

Interview with EMP60 and EMP61 on September 12, 2018, at approximately 10:20 AM confirmed security wanded MR1 and that no concealed metal items or safety hazards were found. EMP60 and EMP61 revealed security does not wand the head or mouth area of a patient for concealed metal items.

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to ensure patients presenting to the Emergency Department (ED) with suicidal thoughts were provided adequate monitoring to prevent self-harm for two of two medical records reviewed (MR1 and MR2); the facility failed to provide physician ordered 1:1 observation monitoring for patients presenting with suicidal thoughts for four of four medical records reviewed (MR3, MR4, MR5 and MR6); and failed to follow the established staffing policy to ensure consistent categories of nursing personnel based on the facility's staffing grid and schedules in the Emergency Department.

Findings include:

Review on September 12, 2018, of the facility's "Suicide Risk Assessment and Interventions in a Non-Behavioral Health Setting" policy, last revised August 2017, revealed "Policy: All patients who are admitted for care and services will be assessed for suicide ideation and /or suicide risk factors during initial intake/admission assessment process. In addition, patients who present for evaluation and treatment with a primary diagnosis or complaint of an emotional or behavioral disorder or substance abuse; or display the symptoms of an emotional or behavioral disorder, will be assessed for suicide risk. Based on the level of suicide risk, interventions will be implemented as a means to keep patients form inflicting harm to self or others. Purpose: To identify patients at risk for suicide and provide safety interventions. ... Definitions: ... Suicidal Ideation: Thoughts of harming or killing oneself. Intensity determined by assessing the frequency, duration and intensity of these thoughts; in addition to the presence of a plan. Suicide Attempt: A non-fatal, self-inflicted destructive act with explicit of inferred intent to die. ... Level of Supervision A. Continuous visual surveillance (Level 1) - one patient to one observer (1:1). Observer must maintain 1:1 direct observation and be able to respond to the patient immediately. De-escalation techniques will be used as appropriate. B. Continuous visual surveillance (Level 2). Patient is under direct observation at all times and observer must be able to respond to the patient rapidly. Ratio may be more than 1:1 as long as observer is able to attend to the immediate needs of one patient without sacrificing surveillance and attendance to the immediate needs of another patient(s). Observer must have direct line of sight of patient. If de-escalation techniques are ineffective, patient will be escalated to Activity Level 1. C. Close observation (Level 3): Patient may not be left alone without support person (may be reliable family/friend). Observation is required by hospital staff at intervals at a maximum of 15-minute intervals. Supportive family/friend must receive education from staff on expected responsibilities and be willing to sign a contract to stay with the patient at all times or know and agree to communicate with/seek staff assistance if chooses to leave for any concerns. In absence of reliable support person, patient will be escalated to Activity Level 2. D. Intermittent observation (Level 4): Observation at a maximum of 30-minute intervals by clinical staff. E. General observation (Level 5): Routine check by clinical staff at a maximum of one-hour intervals. ..."

Review on September 12, 2018, of the facility's "Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting" form, last reviewed April 12, 2018, revealed "Level 1 Definition Requires immediate life-saving intervention. Immediate danger to self or others. Observed Violent Behavior Possession of weapon Self-Destructive act that resulted in physical harm Reported Verbal commands to do harm to self or others (command hallucinations) violent/self-destructive behavior Behavior that has resulted in harm to self or others, including actual suicide attempt Interventions Continuous visual surveillance 1:1 ratio: direct observation by staff at all times. must be able to respond to patient immediately. Use de-escalation techniques. Assess for appropriateness for restraint or seclusion per policy. Obtain Mental Health Professional evaluation. Level 2 High-risk situation Risk of danger to self or others and/or Severe behavioral disturbance Observed Extreme agitation Physically/verbally/aggressive Uncooperative hallucinations/delusions/paranoia distorted perception of reality May or has require(d) restraint/seclusion Words or behavior reflect high risk of elopement (pacing, hovering near doorway) signs of severe depression (Activities of Daily Living impacted) Reported threat to harm self or others Suicidal ideation (thoughts of suicide) with or without a plan acute drug or alcohol intoxication with history of suicide attempt or ideation Psychotic symptoms: Hallucinations, delusions, paranoid ideas, thought disorder, unusual or agitated behavior Overwhelming symptoms of depression Interventions Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation. ..."

Review on September 12, 2018, of the facility's "Suicide Precautions" policy, last revised November 2017, revealed "Purpose: To outline a mechanism for observation and protection of patients who are assessed to be at for suicide, or have expressed suicidal ideations. Policy: 1. A physician's order must be obtained for suicide precautions and psychiatric consult obtained. 2. Suicide precautions must be re-ordered daily. 3. A patient monitor is assigned until the patient is either transferred to an appropriate facility or is determined to be no longer at risk and discontinued. 4. The nurse will inform the patient that he/she is being placed on suicide precautions and explain the rational. 5. The patient on suicide precautions should be assigned the bed near the door in a semi-private room. 6. An environmental safety check of the patient's room will be performed. 7. Patient belongings will be checked closely and all potentially harmful items will be removed, labeled and secured in the designated area on each department. ... 13. The patient monitor is to be seated at the foot of the patient's bed (beyond arms length but in direct proximity of the patient). 10. (sic) The patient monitor will report any potentially unsafe behaviors to the assigned nurse. ..."

Review on September 12, 2018, of the facility's "Prevention/Alternatives and Use of Restraints/Protective Devices" policy, last revised December 2016, revealed "Philosophy: The patient has the right to be free from restraints of any form that are not absolutely medically or behaviorally necessary. Our approach to restrain will protect the patient's health and safety and maintain the patient's dignity. ... Policy: ... 5. The use of restraint must be implemented in accordance with safe and appropriate restraint techniques as determined by hospital policy in accordance with State law. ..."

Review on September 10, 2018, of the facility's "Trauma Alert Activation" policy, last reviewed January 2018, revealed "Purpose: The purpose of this policy is to activate a prescribed group of trained personnel to respond within the hospital and standardize the activation of the trauma team when a trauma patient, who meets the criteria described in this policy, arrives at Wilkes-Bare General Hospital. Scope: This policy applies to any member of the trauma team but is most likely to be initiated by the Emergency Department (ED) attending physician or nurse. Definitions: Trauma Alert (Level I, II, and III): For all patients greater than fourteen (14) years of age. ... Pediatric Trauma Alert: For all patients fourteen (14) years of age or less Trauma Alert - OB: For all patients greater than or equal to 20 weeks gestation Resuscitation: This intense period of patient assessment and medical care to save life or limb Trauma Team: A group of health care professionals organized to provide care and monitor the trauma patient in coordinated and timely fashion Trauma Resuscitation Area: A space used for trauma resuscitation. It must be of adequate size to accommodate for full trauma resuscitation, and equipment. Trauma Resuscitation Team: Major trauma resuscitations require a multidisciplinary team of health care providers who work in synergy to rapidly assess and treat the patient. The trauma attending or appropriate designee must lead the team. ... Procedure: The Trauma Alert response will be determined prior, if at all possible, to the patient's arrival by the Emergency Department physician and /or ED RN or Trauma surgeon. All level I and II trauma alerts will be taken to the trauma resuscitation rooms upon pre-hospital arrival. The Emergency Department physician and /or ED RN or the Trauma Surgeon will initiate a Trauma Alert prior to the arrival of the patient if prior information is available. If no prior notification is obtained, then the Trauma Alert will be called on the patient's arrival in the Emergency Department. The ED physician will give medical commend to ALS/BLS units. The designated Trauma Nurse will notify the switchboard of the classification of Trauma Alert and the estimated time of arrival. ... The ED nurse at the direction of the ED physician activates Trauma Alert Level II. The switchboard will notify the response team to be present upon patient arrival. Trauma Team that will respond will include the following: ... 3. Designated emergency Department trauma nurse ... The ED nurse at the direction of the ED physician activates Trauma Alert Level III. The Trauma surgeon will be paged by the ED physician or Nurse. 1. Emergency Department physician 2. Trauma Surgeon 3. Designated emergency Department trauma nurse. ..."

Review on September 11, 2018, of the facility's "Staffing the Emergency Department" policy, effective June 2015, revealed "Purpose: The purpose of this policy is to explain the methodology for properly staffing the Emergency Department. Policy: Patients presenting to the emergency department are seen as quickly as possible. Staffing must be appropriate for this to occur. ... Procedure: ... 2. Scheduling a. In accordance with the CBA [Collective Bargaining Agreement] and Hospital Policy, emergency Department Leadership issues a six-week schedule in the electronic scheduling program with the maximum number of staff members in each title that would be required at a given hour of the day. ..."

Review of MR1 on September 11, 2018, revealed this patient was admitted to the ED on August 11, 2018, for evaluation and treatment of suicidal ideations and major depression with a history of cutting self. The ED physician ordered 1:1 sitter at the bedside for constant observation at all times on August 11, 2018, on admission to the ED.

Review on September 11, 2018, of MR1's Suicide Risk/Behavioral Disorder Assessment dated August 11, 2018, at 2:15 PM revealed the facility assessed this patient as a Level 1 suicide risk requiring continuous visual surveillance 1:1 ratio: Direct observation by staff at all times. Must be able to respond to patient immediately. Use de-escalation techniques. Assess for appropriateness for restraint or seclusion per policy. Obtain Mental Health Professional evaluation.

Review of MR1 on September 11, 2018, revealed nursing documentation dated August 11, 2018, at 3:00 PM that MR1 was wanded (hand held metal detector) by security. There was no documentation security identified any concealed metal items or safety hazards.

Review of MR1 on September 11, 2018, revealed nursing documentation dated August 11, 2018, at 3:20 PM there was no sitter at the bedside because no sitter was available.

Review of MR1 on September 11, 2018, at 4:45 PM revealed nursing documentation this patient had multiple open lacerations on the arms and front of the neck. MR1's incision/wound charting revealed there were six open lacerations on the arms and front of the neck requiring sutures and 11 lacerations on the arms and front of the neck requiring steri-strips to close the wounds.

Interview with EMP1, EMP3 and EMP7 September 11, 2018, at approximately 9:15 AM confirmed MR1 was admitted to the ED for evaluation and treatment of suicidal ideations and major depression; the ED physician ordered 1:1 sitter at the bedside for constant observation at all times; MR1 was wanded by security; that no concealed metal items or safety hazards were found and MR1's nursing documentation revealed there was no sitter at the bedside because no sitter available. EMP1, EMP3 and EMP7 confirmed MR1's nursing documentation this patient had multiple open lacerations on the arms and front of the neck and this patient's incision/wound charting revealed there were six open lacerations on the arms and front of the neck requiring sutures and 11 lacerations on the arms and front of the neck requiring steri-strips to close the wounds.

Review of MR2 on September 13, 2018, revealed this patient was admitted to the ED on July 29, 2018, at 1:18 AM for evaluation and treatment of a suicidal attempt.

Review on September 13, 2018, of MR2's admission Suicide Risk/Behavioral Disorder Assessment dated July 29, 2018, revealed the facility assessed this patient as a Level 1 suicide risk requiring continuous visual surveillance 1:1 ratio: Direct observation by staff at all times. must be able to respond to patient immediately. Use de-escalation techniques. Assess for appropriateness for restraint or seclusion per policy. Obtain Mental Health Professional evaluation. The ED physician ordered Continuous visual surveillance 1:1 direct observation on this patient.

Review on September 13, 2018, of MR2's Physician's Restraint/Seclusion Orders Violent - Self Destructive order sheet dated July 29, 2018, at 1:10 AM revealed a physician order instructing nursing staff to apply four-point leather restraints. ED nursing staff applied leather restraints to MR2's both wrists and both ankles.

Review of MR2 on September 13, 2018, revealed nursing documentation dated July 29, 2018, at 1:30 AM this patient was being obstructive to self and others by kicking and screaming to staff, thrushing (sic) around in bed, and trying to bite staff. At 1:35 AM on July 29, 2108, nursing documented this patient was able to strangle self with the gown strings. Oxygen was applied to the patient; the patient was hypoxic (inadequate oxygenation of the blood related to suffocation) and the doctor was made aware.

Review of MR2 on September 13, 2018, revealed physician documentation that MR2 was cyanotic (blue discoloration of the skin due to having low oxygen in the blood) and initially not responsive. MR2 was bagged for a few seconds and became awake.

Review of MR2 on September 13, 2018, revealed no documentation this patient was provided a sitter for 1:1 direct observation.

Review of MR2 on September 13, 2018, revealed nursing documentation dated July 29, 2018, at 9:52 AM, 11:03 AM and 3:00 PM that this patient was ordered Level 1 (Continuous visual surveillance). Nursing documentation revealed there was no sitter at the bedside due to the lack of staffing.

Interview with EMP1, EMP3 and EMP7 September 13, 2018, at approximately 9:20 AM confirmed MR2 was admitted to the ED for evaluation and treatment of a suicidal attempt: the facility assessed this patient as a Level 1 suicide risk requiring continuous visual surveillance 1:1 ratio and that MR2 was placed in four-point leather restraints. EMP1, EMP3 and EMP7 confirmed nursing documented this patient was able to strangle self with the gown strings and MR2 became hypoxic requiring oxygen administration. EMP1 and EMP3 confirmed there was no documentation this patient was provided a sitter for 1:1 direct observation and that nursing documented there was no sitter at the bedside due to the lack of staffing.

Review of MR3 on September 13, 2018, revealed this patient was admitted to the ED on July 29, 2018, for evaluation and treatment of suicidal thoughts with a plan to injure self.

Review on September 13, 2018, of MR3's Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting form dated July 29, 2018, revealed the ED physician ordered this patient on Level 2 Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation.

There was no documentation in MR3 indicating this patient was on Level 2 Continuous visual surveillance 1:1 ratio with Observation at all times by designated staff with direct line of sight.

Review of MR4 on September 13, 2018, revealed this patient was admitted to the ED on July 29, 2018, for evaluation and treatment of suicidal thoughts with a plan to injure self.

Review on September 13, 2018, of MR4's Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting form dated July 29, 2018, revealed the ED physician ordered this patient on Level 2 Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation.

There was no documentation in MR4 indicating this patient was on Level 2 Continuous visual surveillance 1:1 ratio with Observation at all times by designated staff with direct line of sight.

Review of MR5 on September 13, 2018, revealed this patient was admitted to the ED on July 29, 2018, for evaluation and treatment of suicidal thoughts with a plan to injure self.

Review on September 13, 2018, of MR5's Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting form dated July 29, 2018, revealed the ED physician ordered this patient on Level 2 Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation.

There was no documentation in MR5 indicating this patient was on Level 2 Continuous visual surveillance 1:1 ratio with Observation at all times by designated staff with direct line of sight.

Review of MR6 on September 13, 2018, revealed this patient was admitted to the ED on July 28, 2018, for evaluation and treatment of suicidal thoughts with a plan to injure self.

Review on September 13, 2018, of MR4's Suicide Risk/Behavioral Disorder Assessment for the Non-Behavioral Health Setting form dated July 28, 2018, revealed the ED physician ordered this patient on Level 2 Continuous visual surveillance 1:1 ratio: Observation at all times by designated staff with direct line of sight. Must be able to respond to patient rapidly. Assess for appropriateness for restraint or seclusion per policy. If de-escalation techniques not effective, escalate to Acuity 1. Obtain Mental Health Professional evaluation.

There was no documentation in MR6 indicating this patient was on Level 2 Continuous visual surveillance 1:1 ratio with Observation at all times by designated staff with direct line of sight.

Interview with EMP3 on September 13, 2018, at approximately 2:45 PM confirmed MR3, MR4, MR5 and MR6 were admitted to the ED for evaluation and treatment of suicidal thoughts with a plan to injure self and the ED physician ordered these patients on Level 2 Continuous visual surveillance 1:1 ratio for observation at all times by designated staff with direct line of sight. EMP3 confirmed there was no documentation in MR3, MR4, MR5 and MR6 indicating these patients were on a Level 2 Continuous visual surveillance 1:1 ratio with observation at all times by designated staff with direct line of sight.

Interview with EMP29, EMP30 and EMP31 on September 10, 2018, revealed there is not always a Flow/Trauma Nurse always assigned to cover this position. These employees revealed when a trauma patient presents to the ED, and there is no Flow/Trauma Nurse coverage, a RN is pulled from their patient assignment to cover the trauma.

Review on September 11, 2018, of the ED staffing sheets for August 1, 4, 8, 12, 13, 14, 17, 19, 20, 21, 22, 25, 26, 27 and 28, 2018, revealed no designated Flow/Trauma Nurse coverage.

Review on September 11, 2018, of the ED trauma list for August 2018, revealed the following trauma patients presented to the ED:
August 8, 2018: 2 - Level II trauma patients
August 13, 2018: 1 - Level 2 trauma patients
August 20, 2018: 1 - Level I trauma patient
August 21, 2018: 1 - Level I trauma patients
August 25, 2018: 1 - Level I trauma patient; 3 - Level II trauma patients and 1 - Level III trauma patient
August 26, 2018: 1 - Level I trauma patient and 1 - Level III trauma patient
August 29, 2018: 1 - Level I trauma patient

Interview with EMP3 and EMP7 on September 11, 2018, at approximately 10:45 AM confirmed there was no designated Flow/Trauma Nurse coverage on August 1, 4, 8, 12, 13, 14, 17, 19, 20, 21, 22, 25, 26, 27 and 28, 2018. EMP7 confirmed when trauma patients present to the ED and there is no designated Flow/Trauma Nurse coverage, a RN is pulled from their assignment to cover the trauma.

Review on September 11,2 018, of the ED staffing sheets for September 4, 5, 6, 7 and 9, 2018, revealed no designated Flow/Trauma Nurse coverage.

Review on September 11, 2018, of the ED trauma list for September 2018, revealed the following trauma patients presented to the ED:
September 4, 2018: 3 - Level I trauma patients and 1 - Level II trauma patient
September 5, 2018: 1 - Level 2 trauma patients
September 6, 2018: 1 - Level I trauma patients; 2 - Level II trauma patients and 1 - Level III trauma patient
September 7, 2018: 2 - Level II trauma patients

Interview with EMP3 and EMP7 on September 11, 2018, at approximately 12:00 PM confirmed there was no designated Flow/Trauma Nurse coverage on September 4, 5, 6, 7 and 9, 2018. EMP7 confirmed when trauma patients present to the ED and there is no designated Flow/Trauma Nurse coverage, a RN is pulled from their assignment to cover the trauma.
Review on September 10, 2018, of the facility provided the "Emergency Department Staffing Grid " dated June 16, 2018, revealed the required staffing at 7 AM is 10 Registered Nurses (RN's), 1 RN for Crisis, 2 Techs; 1 Nurse Assistant (NA) and 1 Unit Secretary (US); at 9 AM the required staffing is 12 RN's, 1 RN for Crisis, 2 Techs; 2 NA's and 1 US; at 11 AM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 3 PM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 7 PM the required staffing is 16 RN's, 1 RN for Crisis, 2 Techs; 4 NA's and 2 US's; at 11 PM the required staffing is 14 RN's, 1 RN for Crisis, 2 Techs; 2 NA's and 1 US; and at 3 AM the required staffing is 8 RN's, 1 RN for Crisis, 2 Techs; 1 NA and 1 US."

Interview with EMP3 on September 10, 2018, at approximately 8:00 PM revealed the time from 11:00 AM to 7:00 PM are the busiest times with more patient visits in the ED. EMP3 revealed staffing numbers are increased during this time due to the increase in patient visits.

Interview with EMP29, EMP30, EMP31, EMP32, EMP33, EMP34, EMP35, EMP36, EMP37 and EMP38 on September 10, 2018, revealed there is inadequate staffing of Registered Nurses (RN), Techs, Nursing Assistants (NA's) and Unit Secretary's (US) in the ED.

On September 10, 2018, a random sample of the ED staffing sheets for August 2018 and September 2018 were selected for review.

Review on September 11, 2018, of the staffing sheets for August 1, 3, 4, 5, 6, 10, 11, 12, 20, 21, 25, 27, and 31, 2018, revealed the facility did not meet the required staffing per the staffing grid for the ED.

Interview with EMP3 on September 11, 2018, at approximately 10:15 AM confirmed the facility did not meet the required staffing for RN's, Techs, NA's and Unit Secretary's per the established staffing grid in the ED for August 1, 3, 4, 5, 6, 10, 11, 12, 20, 21, 25, 27, and 31, 2018.

Review on September 11, 2018, of the staffing sheets for September 2, 4, 5, 6, and 9, 2018, revealed the facility did not meet the required staffing per the staffing grid for the ED.

Interview with EMP3 on September 11, 2018, at approximately 12:00 PM confirmed the facility did not meet the required staffing for RN's, Techs, NA's and Unit Secretary's per the established staffing grid in the ED for September 2, 4, 5, 6, and 9, 2018.