HospitalInspections.org

Based on policy review, complaint log review, medical record reviews, internal document review, and interviews the hospital staff failed to collect and analyze data for quality assurance purposes as reassurance of the effectiveness of staff education for the new process of scanning guardianship documents into the electronic medical record for 1 of 1 patient with a guardian (Patient #5) and for 1 of 1 patient without a guardian (Patient #4).

Findings included:

Review on 6/15/2023 of the hospital's "Quality Assessment and Performance Improvement Plan" calendar year 2022 revealed, " ...I. Purpose: The Quality Assessment and Performance Improvement (QAPI) Program for [hospital name] has been developed to prevent harm and improve patient outcomes through systemic approach to patient centered care. ..."

Review on 6/13/2023 of the complaint log revealed on 4/04/2022, the guardian for patient #5 filed a complaint. The details of the complaint revealed, the hospital emergency department staff notified and discharged the patient home with [family] without notifying the guardian despite guardianship documents which were provided to the emergency department registration staff. As a result, corrective actions included follow-up with the registration staff wherein, the complaint was used as a coaching opportunity with weekly education of the process of scanning guardian documents into the electronic medical record. Review revealed the registration department received a complaint.

1. Closed medical record review on 6/13/2023 revealed on 3/29/2022 at 1257, patient #5, a 68-year-old patient presented to the hospital's emergency department under involuntary commitment. At 1334, the guardian presented to the hospital. The guardian signed the consent for treatment and guardianship documents were provided to the emergency department registration staff. The patient received interdisciplinary care that included a psychiatric consult. The consultation was performed at 1636 and determined the patient did not meet criteria for involuntary commitment. The patient was deemed medically and mentally stable for discharge. At 1712, the involuntary commitment was reversed, and at 1814, the patient was discharged to home with [family]. Review revealed, the hospital staff discharged a patient without notifying the guardian beforehand.

Interview on 6/14/2023 at 1155 with the registration supervisor revealed, the guardian for patient #5 provided guardianship documents to the emergency department registration staff. The staff scanned documents under the benefit tab and not the guardian tab. At discharge, the guardian was not present. The patient's family listed in the electronic medical record was contacted and picked the patient up from the emergency department. As a result, a complaint was filed, and a discussion was held with the former registration staff that scanned the guardian documents into the wrong section of the electronic medical record. A huddle was held with the registration staff and an email went out to all registration staff regarding placement of guardian documents in the electronic medical record. Weekly follow-ups occurred and the topic was discussed in the quality meetings at the hospital and market levels. Interview revealed the registration staff was educated on where guardian documents should be scanned into the electronic medical record.

Interview on 6/14/2023 at 1535 with the registration supervisor revealed from 4/20/2023 through 5/20/2023 (30-days), monitoring occurred as the registration staff scanned legal guardianship documentation into the electronic medical record. The compliance goal was 95% as daily and weekly monitoring occurred, and the monitoring data was reported up to the market level. Interview revealed the registration supervisor was unable to provide monitoring data for review.

Interview on 6/15/2023 at 1330 with the Director of Compliance and the registration supervisor revealed, the facility had a process for scanning guardian documents into the electronic medical record, in which staff training only occurred upon hire. The process was if a patient had a guardian, staff should click onto the "demographic" tab and click guardian. This entry would then show up on the "story board" on the upper left side of the patient's electronic medical record. Additionally, if the patient had a healthcare agent, that information could also be entered under the "demographic" tab and if would be highlighted in "yellow" on the story board of the electronic medical record. If guardian documents were presented upon a patient's arrival, staff should scan the document into the appropriate section of the medical record. Staff such as nurses, physicians, and care coordinators had access and the ability to update information in the patient's chart at any point during the patient's hospitalization. Interview revealed the registration staff received education related to scanning documents under the correct tab in the electronic medical record, but no monitoring data was available for review.

2. Closed medical record review on 6/14/2023 revealed on 12/8/2022 patient #4 presented to the hospital's emergency department for a psychiatric evaluation. On 12/12/2022 (4-days later) the patient was transferred out to another facility for continued treatment. Review revealed no guardian was listed for the patient's 12/2022 hospital visit.

Interview on 6/14/2023 no time documented with care coordinator revealed at the time of the interview, the coordinator changed the guardian data for patient #4 from no guardian to [county social worker] because the coordinator was familiar with the [county social worker]. Interview failed to reveal the care coordinator received guardianship documents before changes were made in the electronic medical record for the 12/22/2022 hospital encounter.

Interview on 6/14/2023 at 1155 with the registration supervisor revealed, the registration department received a complaint was filed for not scanning guardian documents into the correction location in the electronic medical record and failure to notify the guardian prior to discharging a patient home with [family]. As a result, a discussion was held with the former registration staff that scanned the guardian documents into the wrong section of the electronic medical record. A huddle was held with the registration staff and an email went out to all registration staff regarding placement of guardian documents in the electronic medical record. Weekly follow-ups occurred and the topic was discussed in the quality meetings at the hospital and market levels. Interview revealed the registration staff and not the care coordinator were educated on where guardian documents should be scanned into the electronic medical record.

Telephone interview on 6/15/2023 at 0858 with [county social worker] revealed patient #4 had not been under guardianship since 2020 due to restoration of competency.

Interview on 6/15/2023 at 1330 with the Director of Compliance and the registration supervisor revealed, the facility had a process for scanning guardian documents into the electronic medical record, in which staff training only occurred upon hire. The process was if a patient had a guardian, staff should click onto the "demographic" tab and click guardian. This entry would then show up on the "story board" on the upper left side of the patient's electronic medical record. Additionally, if the patient had a healthcare agent, that information could also be entered under the "demographic" tab and if would be highlighted in "yellow" on the story board of the electronic medical record. Also, if guardian documents were presented upon a patient's arrival, staff should scan the document into the appropriate section of the medical record. Staff such as nurses, physicians, and care coordinators had access and the ability to update information in the patient's chart at any point during the patient's hospitalization. Interview revealed the registration staff and not the care coordinator received education related to scanning documents under the correct tab in the electronic medical record however, no monitoring data was available for review.

Based on policy review, medical record review, and staff interviews, the hospital failed to complete nursing assessments every 12 hours in the emergency department in 2 of 5 patient records reviewed (Patient #4, Patient #6) and failed to reassess a patient's vital signs prior to discharge in 2 of 5 patients records reviewed. (Patient #5, Patient #8)

Review of the policy Nursing Assessment and Documentation in the Emergency Department, effective date 10/26/2021 revealed "...PURPOSE The purpose of this policy is to ensure appropriate application of Emergency Severity Index (ESI) to guide nursing care, monitoring and documentation within the Emergency Department (ED) and provide guidance in assessment of pertinent information that could impact patient care. Policy Guidelines...B. Treatment Area ...1. c. An adult assessment will be repeated every 12 hours or as indicated by Patient condition...C. Disposition 1. Discharge: c. Vital signs will be reassessed prior to patient discharge..."

1. Closed medical record review on 06/14/2023 revealed Patient #6, a 14-year-old male patient admitted to the emergency department (ED) for a psychiatric evaluation, and suicidal ideations on 01/18/2023 at 1534. Review of the ED Care Timeline revealed Patient #6 "...arrived with his brother for voluntary commitment. Pt. (patient) states he has fits of rage and attempts self-harm. Pt. has marks on his arm that are in different stages of healing." Patient was assigned ED Registered Nurse (RN) #17, and initial vital signs at 1600 were temperature 98.1 orally. respirations 18, blood pressure 153/67, 98 % oxygen, and pulse of 110 and a suicide screening was completed as negative for risk. At 1617 Patient #6 was assigned an ESI of 2-Emergent (Emergency Severity Index, acuity, on a scale of 1-5 where 1 is most acutely ill and 5 is least acute). At 1639 MD #18 saw Patient #6, and a Psychiatric Evaluation order was placed. At 1830 a one-to-one sitter was assigned and at 1854 the IVC (Involuntary Commitment) was served at 1949. At 1954 Patient #5's Mother was documented at the bedside, and 2005 vital signs were temperature orally 99.4, pulse 65, respirations 20, blood pressure 98/63. oxygen was 100 %. Review of the Telepsychiatry Consultation Note dated 01/19/2023 at 1013 by MD #19 revealed an inpatient psychiatric hospitalization was recommended at this time. Review of the ED Care Timeline 01/19/2023 1900 through 01/20/2023 0700 failed to reveal a Nursing Assessment was completed by RN #26. On 01/20/2023 at 1454 Patient #6 was moved to ED Behavioral Health-room 3 from Fastrack room 6. Review of the ED Care Timeline 01/20/2023 1900 through 01/21/2023 0700 failed to reveal a Nursing Assessment was completed (no RN was documented as assigned to Patient #6 during nightshift). On 01/21/2023 at 0804 Telepsychiatry MD #21 noted "...he would prefer to go home...Stable in terms of mood, behavior and affect...If he demonstrates continued stability through the weekend with no placement, then will recommend discharge to care of his mother..." Review of the ED Provider Notes dated 01/21/2023 at 1643 with MD #22 revealed Patient #6's mother was here to pick him up, "...reversal of IVC paperwork." Patient #6 was discharged home with his mother on 01/21/2023 at 1714. Record review revealed 2 of 6 Nursing Assessments were not completed during a 3-day length of stay in the ED.

Request to interview RN #26 on 06/14/2023 revealed she was unavailable for interview.

Interview on 06/15/2023 at 1400 with ED Nurse Manager, RN #6 revealed every patient should have a nursing assessment every 12 hours while in the ED. Interview revealed "...the biggest area of application for nursing reassessments are with mental health patients due to their length of stay, we do have a lot of improvement with mental health patient reassessments..." Interview revealed hospital policy was not followed for nursing reassessments for Patient #6.

2. Closed medical record review on 06/13/2023 revealed Patient #5, a 68-year-old male who arrived 03/29/2022 at 1257 to the ED by emergency medical services (EMS) under involuntary commitment (IVC) for "Failure to Thrive". Review of the ED Care Timeline documentation revealed Patient #5 was assigned to ED RN #9 and was seen by ED Medical Doctor (MD) #1 at 1304 "...Patient is IVC (involuntary commitment). Patient reportedly is not eating, paying bills, or taking care of himself. Alert and oriented X (times) 4. Denies SI (suicidal ideation), HI (homicidal ideation). Bgl (blood glucose) 109 (normal blood glucose 60-100). Patient has visible bed bugs upon arrival to the ED..." At 1307 lab work was ordered; complete blood count, comprehensive metabolic panel, lipase, and at 1314 a Suicide Risk Assessment was completed by Registered Nurse (RN) #2 and was negative for risk factors. Initial vital signs at 1315 were Pulse: 95, Respirations: 18, Blood Pressure (BP) 160/100, and oxygenation at 97% on room air (no temperature was taken), triage was completed by RN #2 and Patient #5 was assigned an acuity ESI 2-emergent. At 1330 a repeat blood pressure was taken 146/83. At 1334 Consent to Treat was signed by the department of social services (DSS) legal guardian who was onsite. At 1339 a Cat Scan (CT) of the head was ordered and at 1429 a Virtual Consult to Psychiatry was placed by MD #1. On 03/29/2022 at 1636 the Psychiatry Consult was completed by MD #3 "...under IVC by his guardian (ward of the state) for failure to thrive and poor self-care...Patient does not meet criteria for IVC in NC (North Carolina) due to not having a psychiatric illness, and does not require acute inpatient psychiatric hospitalization..." At 1656 CT of the Head resulted as negative, and at 1702 the ED Disposition was set to Discharge by MD #1. Review of the ED Provider Note at 1706 by MD #1 revealed lab results were reviewed and Patient #5 was deemed stable, and at 1718 a reversal of the IVC was completed, "...He reports he feels safe at home...Brother-n-law made aware of pending discharge, and he is comfortable with it. No other events under my care." 1814 Patient #5 was discharged home by RN #9. Record review failed to reveal reassessment of a vital signs taken prior to Patient #5's discharge.

Interview on 06/14/2023 at 1015 with ED RN #9 revealed she did not remember Patient #5. Interview revealed "...if I discharge my patients, I write a note before discharge. I never assigned myself to this patient...I don't remember taking care of him...Reassessments for ESI 2 patients are every one hour..." Interview revealed sometimes the ED Charge Nurse will assign a nurse to a patient's electronic medical record based off the nursing room assignment made each day. Interview revealed RN #9 did not remember taking care of Patient #5 nor discharging him. Interview revealed discharge vital signs should be taken prior to patient discharge. Interview revealed hospital policy was not followed.

Interview on 06/15/2023 at 1400 with ED Nurse Manager, RN #6 revealed "...vital signs should be taken within 60 minutes of patient discharge or transfer and documented..." Interview revealed hospital policy was not followed for Patient #5.

3. Open medical review on 06/14/2023 revealed Patient #8, a 15-year-old male admitted to the ED for suicidal ideation on 06/09/2023 at 2242. At 2255 vital signs were temperature 98.3 orally, pulse 116, respirations 20, blood pressure 147/75, oxygen 99 % and ESI of 2-emergent was assigned by RN #25. Review of the ED Provider Notes dated 06/09/2023 at 2316 by ED MD #23 revealed Patient #8 was accompanied by his mother, reporting thoughts of hurting himself and had called 911 from a gas station, he was evaluated and placed in psychiatric observation at 2311, and a Telepsychiatry evaluation was ordered. Patient #8 was placed under IVC at 0210. Telepsychiatry Consult on 06/10/2023 at 0750 with MD #24 revealed insufficient findings of IVC criteria. 1129 Discharge disposition set to discharge by MD #22, and at 1443 Patient #8 was discharged home with Mother by RN #12. Record review failed to reveal reassessment of a vital signs taken prior to Patient #8's discharge.

Interview on 06/15/2023 at 1345 with ED RN #12 revealed she did not remember Patient #8. Interview revealed "...vital signs should be taken within one hour of patient discharge and should be documented..." Interview revealed hospital policy was not followed for Patient #8.

Interview on 06/15/2023 at 1400 with ED Nurse Manager, RN #6 revealed "...vital signs should be taken within 60 minutes of patient discharge or transfer and documented..." Interview revealed hospital policy was not followed for Patient #8.

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2. Closed medical record review on 06/13/2023 revealed Patient #4 was a 58-year-old female who presented to the hospital Emergency Department (ED) on 12/08/2022 at 1633 via Law Enforcement. Patient #4 had a 3-day length of observation encounter in the ED with a chief complaint of Psychiatric Evaluation. Review revealed the hospital had Patient #4 Involuntarily Committed with collaborative information from family members. Review revealed Patient #4 had a Telepsychiatry Evaluation on 12/09/2022 which revealed documentation by the ED physician to seek inpatient placement for admission. Review failed to reveal a completed Nursing Assessment on 12/09/2022 for nightshift (1900 - 0700), 12/10/2022 for dayshift (0700 - 1900), 12/11/2022 for dayshift and 12/11/2022 for nightshift. On 12/12/2022 at 1053, Patient #4 was transferred to an outside Inpatient Psychiatric facility. Record review failed to reveal documentation of 4 of 6 Nursing Assessments during a 3-day length of observation encounter in the ED.

Interview on 06/14/2023 at 0956 with the ED Registered Nurse Manager (RN) #6 revealed it was the expectation that the Nursing Assessments should be completed every shift for patients that were deemed stable in the ED.

Interview with the assigned RN #10 to Patient #4 on 12/09/2022 for nightshift was unavailable for interview.

Interview with the assigned RN #12 to Patient #4 on 12/10/2022 and 12/11/2022 for dayshift was unavailable for interview.

Interview with the assigned RN #11 to Patient #4 on 12/11/2022 for nightshift was unavailable for interview.

Interview with MD #14, the Medical Doctor for Patient #4 was unavailable fo interview.

Based on review of the hospital policy Code Blue Plan, Emergency Department Code Cart logs and staff interviews the hospital nursing staff failed to complete the Code Cart Daily Checklists to maintain the department equipment to ensure an acceptable level of safety and quality applied to 4 of 4 Emergency Code Carts available in the Emergency Department for patient care.

Findings included:

Review of the hospital policy Code Blue Plan, effective date 09/27/2022 revealed "PURPOSE The purpose of this policy is to provide resuscitative services to any victim suffering respiratory and/or cardiac distress and/or arrest ...POLICY GUIDELINES ...5b. Each department's leader is responsible for ensuring the emergency equipment is checked daily. This department leader will assign an individual(s) the responsibility of performing code cart inventory checks as prescribed by this policy ..."

Observation during tour of the Emergency Department (ED) on 06/13/2023 at 1100 revealed the unit had 4 Emergency Code Carts available for the unexpected need to perform Cardiopulmonary Resuscitation (CPR, used to revive a patient during a life-threatening event) for patient care. The unit observation failed to reveal daily checks were conducted on March 18th, April 22nd, May 24th, June 3rd, and June 4th for the Emergency Code Cart of the Fast Track area (5 of 91 days reviewed). The unit observation failed to reveal daily checks were conducted on March 18th and March 31st for the Behavior Health Holding area (2 of 91 days reviewed). The unit observation failed to reveal daily checks were conducted on March 18th and June 3rd for Emergency Department Room #01 (2 of 91 days reviewed). The unit observation failed to reveal daily checks were conducted on May 18th, June 7th, and June 8th for Emergency Department Room #02 (3 of 91 days reviewed). Observation revealed there was no documentation of an Emergency Department Code cart check for a total of 12 of 91 days reviewed.

Interview on 06/13/2023 at 1210 with the Manager of the Emergency Department revealed the Manager had worked in the department for 12 years and over 4 years as the Manager of the ED. Interview revealed that it was the expectation of the ED Manager for staff to check all four of the Emergency Code Carts daily. The interview revealed ultimately it was the Charge Nurse who was responsible to ensure that staff were assigned to check the Emergency Code Carts daily.

Interview on 06/15/2023 at 0930 with the Chief Nursing Officer of the hospital revealed the expectation was to have the Emergency Code Cart checked daily for adequate supplies and equipment to be in proper function for patient use.
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