HospitalInspections.org

Based on document review, record review and interview, it was determined the Governing Body (GB) failed to assume responsibility for the operation of the hospital.
Failure by the GB to provide effective oversight for care and services provided in the Dedicated Emergency Department (DED) exposed all patients coming to the hospital seeking emergency care to the potential for serious injury, harm and/or death resulting in IMMEDIATE JEOPARDY.
The findings included:

1. The GB failed to ensure the medical staff was accountable for ensuring the quality of care provided in the DED was based on performing an appropriate examination and prescribing treatment according to the findings for patients presenting to the DED seeking medical care.
Refer to A049

2. The GB failed to ensure the Chief Executive Officer (CEO) assumed responsibility for operation of the hospital DED and for implementation of the QAPI and Infection Control programs.
Refer to A057.

3. The GB failed to ensure the hospital ' s Quality Assessment Performance Improvement (QAPI) program identified, addressed, and provided interventions to ensure their resolutions.
Refer to A263 and A275.

4. The GB failed to ensure the Medical Staff provided care and services with the patient ' s best interest in mind. The Medical Staff failed to ensure all patients who presented to the hospital ' s DED received appropriate and adequate medical screening examination (MSE), treatment and care within the hospital ' s capabilities.
Refer to A338 and A347.

5. The GB failed to ensure the Infection Control (IC) program tracked and trended infections and qualified personal were appointed as the IC Officer.
Refer to A747, A748, and A749.

6. The GB failed to ensure physician oversight in the DED in order to provide patients seeking medical attention an appropriate MSE to determine if an emergency medical condition existed and failed to ensure protocols were developed and used to assist non-physician personal with performing an appropriate MSE to determine if an emergency medical condition existed prior to patients being treated and released. The GB failed to ensure staff working in the DED possessed required skills and competencies necessary to assess patients and to determine patients were stable for discharge.
Refer to A1104 and A1112.

Based on document review, record review and interview it was determined the Governing Body failed to assume responsibility for care provided to the patients by the Medical Staff who failed to ensure an appropriate examination was performed and treatment was prescribed according to the findings for 16 of 24 (Patients #8, 11, 14, 23, 24, 25, 26, 27, 28, 29, 31, 32, 33, 34, 35 and 36) sampled patients presenting to the Dedicated Emergency Department (DED) seeking medical care.

Failure by the GB to provide effective oversight for care and services provided in the Dedicated Emergency Department (DED) exposed all patients coming to the hospital seeking emergency care to the potential for serious injury, harm and/or death resulting in IMMEDIATE JEOPARDY.


The findings included:

1. Review of the DED staff meeting minutes dated 6/27/11 documented an issue had been identified with patients who had presented to the DED and had not been seen by physicians and practitioners. The meeting minutes documented the physicians and practitioners would be allowed to document on the patient's DED records even if they had not seen the patients.

2. Medical record review for Patients #8, 11, 14, 23, 24, 25, 26, 27, 28, 29 31, 32, 33, 34, 35 and 36 revealed the patients presented to the DED on dates from 7/11 - 11/11. The patients DED records documented the patients had not been seen by physicians and/or practitioners on the days they had presented to the DED. Documentation on the patients's DED records revealed Physician #1 and Physician #2 had documented assessments and diagnoses for the patients and that treatment such as medications had been administered even though the DED record and central logs documented patients were not seen by the physician.

3. Review of the Central Log from 7/3/11 - 11/9/11 revealed patients #8, 11, 14, 23, 24, 25, 26, 27, 28, 29 31, 32, 33, 34, 35 and 36 were not seen by the physician or practitioner.

4. During an interview on 11/15/11 at 1:25 PM, the DED Supervisor verified a zero (o) with a strike through the middle placed in the area designated for recording the physician's arrival to the ED meant the patient was not seen by the physician. When shown a medical record with this symbol but also having documentation indicating an assessment was performed, a diagnosis made and a signature present, the DED Director stated the physician had come to the DED and documented on the patient's record and that the physician was not saying he had seen the patient he was just documenting an assessment.

During an interview in the DED on 11/15/11 at 1:50 PM, the DED Supervisor was asked if there had been an identified pattern with any physician or practitioner not physically assessing emergency department patients. The DED Supervisor stated she had identified a pattern with Physician #1. The surveyor asked the DED Supervisor if there were instances when Physician #1 was in the building and did not come to see the DED patient. Her answer was, "Yes ma'am."

During an interview on 11/16/11 at 12:30 PM the DED Supervisor stated the documentation on the patients's DED records and Central Logs verified those patients had not been seen by Physician #1 while the patients were in the DED.

5. During an interview on 11/16/11 at 9:20 AM the Director of Clinical Services verified the words "Not Seen" meant the patient was not seen by the physician.

6. During an interview on 11/16/11 at 9:40 AM the Director of Nursing (DON) verified a zero with a strike through the middle meant the patient was not seen.

7. During a telephone interview on 11/17/11 at 8:55 AM, Physician #1 stated he did at times examine patients somewhere else such as the hallway of the hospital and stated, "I check them briefly" then go to the DED and write on the chart but "it may be the next day or some little bit later... it's a common thing..." When the surveyor sought clarification by asking if sometimes when patients were examined they were no longer in the DED, Physician #1 stated he did examinations in the DED "Most of the time." When questioned as to what "not seen" on the patient's DED record meant, Physician #1 stated, "We do see them from time to time inpatient and outpatient..." Additionally Physician #1 stated, "They [patients] want their shot or they will leave."

Refer to A 0347, A1104


19001

Based on policy review, record review and interview, the Chief Executive Officer (CEO) failed to assume responsibility for the operation of the hospital Dedicated Emergency Department (DED) and necessary programs.

Failure by the CEO to assume responsibility and provide oversight for care provided in the DED and to ensure an effective Quality Assessment Performance Improvement (QAPI) program was maintained placed patients coming to the DED seeking emergency care at risk for potential serious injury, harm and/or death resulting in IMMEDIATE JEOPARDY.

The findings included:


1. Review of the DED records for Patients #8, 11, 14, 23, 24, 25, 26, 27, 28, 29, 31, 32, 33, 34, 35 and 36 documented the patients had presented to the DED seeking medical attention. The patient's DED records documented these patients had not been seen but the LPN and RN had initiated an assessment, provided treatment and discharged the patient. Interviews with the DED Supervisor, Director of Nursing (DON) and Physician #1 revealed DED Physician #1 does not see all the patients who present to the DED seeking medical attention and Physician #1 does document an assessment and diagnosis of patients without physically examining them. Review of the DED staff meeting minutes documented the hospital had knowledge of this practice.


Review of the hospital's DED policies and procedures documented the RN was approved by the By-laws to perform a Medical Screening Examination (MSE) using a complaint specific protocol to determine if an emergency medical condition exists. There was no documentation the RN had used the complaint specific protocols to determine if an emergency medical condition exists. During an interview the DED Supervisor verified the RN did not use complaint specific protocols to determine if an emergency medical conditions existed.

Review of the hospital's DED policies documented the assessment process begins at triage. Review of the DED records documented the LPN performed the triage assessment. Review of the Rules of the Tennessee Board of Nursing documented LPNs were not qualified in the State of Tennessee to perform assessments.

2. Review of the QAPI meeting minutes revealed no documentation the hospital had discussed the practice of physicians not seeing patients in the DED and identified interventions to ensure patients presenting to the DED received appropriate care and treatment.


3. Review of the Infection Control meeting minutes revealed no documentation the hospital had developed a system to track and trend infections. Review of the hospital's Infection Control policy and Infection Control Officer's job description documented the Infection Control Officer should be a Registered Nurse (RN). During an interview the Infection Control Officer revealed the Infection Control Officer was a Laboratory Technologist. During an interview the Administrative Assistant revealed the hospital was aware the Infection Control Officer should be a RN.

During an interview the Housekeeping Supervisor revealed the Supervisor was unaware of the contact time of the cleaning solution and blood to avoid possible contamination.

Review of the dietary department revealed refrigerator temperatures were 60 degrees on 3 separate occasions. Opened items in the refrigerator were not dated and labeled and corrugated boxes were used for food storage.

Refer to A 0263, A 0275, A 0276, A 0285, A 0338, A 0347, A 0620, A 0747, A 0748, A 0749, A 0750, A 1104 and A 1112

Based on document review, record review, policy review and interview, it was determined the facility failed to implement, and maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement program with the care and services of the patient's best health interest in mind. Failure to recognize and act on issues surrounding adequate assessments in the DED exposed all patients coming to DED seeking emergency department treatment to potential for serious injury, harm and/or death resulting in IMMEDIATE JEOPARDY.

The findings included:

1. The facility failed to monitor, track, trend, identify deficits, implement improvements and monitor the safety of services and quality of care for the patients in the dedicated emergency department (DED) and concerning infection control hospital wide.
Refer to A275

Based on policy review, document review, medical record review and interview, it was determined the facility failed to maintain an active and ongoing Quality Assessment and Performance Improvement (QAPI) program to monitor infections and the safety of services and quality of care for the patients in the dedicated emergency department (DED). Failure to have an active and ongoing QAPI program concerning infection control and the DED exposed the patients to potential for serious injury, harm and/or death resulting in IMMEDIATE JEOPARDY.

The findings included:

1. Review of the hospital's policy, "PERFORMANCE IMPROVEMENT PLAN" documented, "...The purpose of the Quality Improvement Plan is to ensure the delivery of quality patient care and to provide a means of continuously improving the quality by providing a guide for the application of Quality Assessment-Performance Improvement and Management of information...[named hospital] leaders have responsibility to actively participate in the quality improvement system...The focus of quality improvement will be on understanding and improving the processes that compose the important functions identified...Based on current knowledge and clinical experience, teams will be used to develop and select indicators for use in quality improvement activity. These indicators will be measurable, specific, objective events which will provide information useful in assessing the quality of important aspects of care or service. Departments should assure that intra-and interdepartmental indicators are developed. Actual performance evaluation measures may be directed at one or more of the dimensions of quality: appropriateness, effectiveness, what does or does not happen after a patient care function is performed or not performed, clinical criteria and/or standards of care...When the trigger is reached for evaluation, appropriate staff members or teams should evaluate care/service extensively to see if an opportunity for improvement exist...If the needed action exceeds the authority of the unit, team or committee, recommendations will be forwarded to the body having the authority to act (Quality Council)... Topics for review will include but not be limited to: Determining whether areas for improvement were identified, acted upon, and patient care and services improved..."

A. Review of the DED central logs documented Patients #8, 11, 14, 23, 24, 25, 26, 27, 28, 29, 31, 32, 33, 34, 35 and 36 were "not seen" Under the area physical exam/history/orders there was documentation of an assessment of the patient and a diagnosis which was signed by DED Physician #1 or ED Physician #2.

B. Review of the facility's "Emergency Department Staff Meeting Minutes" dated 06/27/11 documented, "...I do not know how many times I have said this, but if a Doctor or Practitioner DOES NOT see a patient, then you must document "not seen" in the space provided on the ER and logbook. We can not bill for Doctor/Practitioner if not seen. The Doctor/Practitioner is welcome to document whatever he/she wants, but we cannot bill..."

C. Review of the DED's list of indicators "ER [Emergency Room] Monitoring and Evaluation (Revised April 2000)" documented, Emergency pt [patient] is seen by a doctor and a threshold of 100%.

D. Review of the DED's "Emergency Department Monitoring & Evaluation Worksheet" dated June 2011 through November 10, 2011 contained no documentation of the indicator Emergency patient seen by a doctor.

E. Review of the facility's "Quality Council Minutes" dated 7/21/11 and dated 10/20/11 contained no documentation reflecting the 6/27/11 DED staff meeting minutes identifying the Doctor or Practitioner not seeing a patient was an opportunity for improvement.

2. Review of the hospital's policy, "Emergency Medical Treatment", documented, "Any individual who comes to the emergency department and requests examination or treatment for a medical condition is entitled to and will receive an appropriate medical screening examination (MSE) ...The medical screening examination is an ongoing process based on the patient's needs and continue until the patient is either stabilized or appropriately transferred...How to Provide the Medical Screening Examinations...The medical screening examination shall include both a generalized assessment and a focused assessment...A medical screening examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation prior to discharge or transfer along with documentation of the process...When non-physician personnel perform the medical screening examinations, screening protocols that outline the examination and/or diagnostics workup required to determine if an emergency medical condition exits should be developed and approved by the hospital's medical staff. These protocols will normally be complaint specific and will be limited to those presented complaints that lend themselves to screening by such non-physician personnel... Emergency medical condition... A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and/or symptoms of substance abuse)..."

A. Review of the medical records for Patients #8, 11, 14, 23, 24, 25, 26, 27, 28, 29, 31, 32, 33, 34, 35 and 36 revealed RNs (Registered Nurse) initiated the MSE but failed to use a complaint specific protocol to determine if an emergency medical condition existed, failed to continue an ongoing assessment of the patients and failed to assess patients prior to discharge and post treatment to determine if the patients were stabilized.

B. During an interview in the conference room on 11/16/11 at 8:50 AM, the DED night supervisor stated the RN would perform an MSE on the patients presenting to the DED. The DED night supervisor stated the LPN is alone with the patients, administers medications and makes the determination when the patient is stabilized to be discharged home.

C. During an interview on 11/16/11 at 9:00 AM, the DED Supervisor stated the hospital did not have a complaint specific protocol for the RNs to use to determine if an emergency medical condition exists.

D. During an interview on 11/15/11 at 1:25 PM the DED supervisor was questioned about the DED committee meetings. The DED supervisor stated after the RN performed the medical screening examination (MSE), the RN would call the doctor that's on call in the building. If the doctor knows the patient he would prescribe medications to be given by the nurse. The ED Supervisor stated there have been times the doctor on-call does not see the patient in the DED. When asked if the DED supervisor had identified a problem with DED physician(s) not seeing patients in the DED, she stated, "Yes, I have taken it to [named Director of Clinical Services] and [named Director of Nursing], also mentioned to [named Administrative Assistant]." When questioned about the outcome of reporting her concerns, the DED supervisor stated, "It [practice] continues." The DED supervisor was asked where the physician is when the nurse calls regarding the patient, she stated, "...at night in doctors lounge, he's [physician] asleep...may come back later that shift and document..."
E. During an interview in the conference room on 11/16/11 at 10:35 AM, the DED supervisor was asked who she made aware of her concerns of patients in the DED receiving treatment and not being seen by a physician. The DED supervisor stated, "[named DON] and named [Director of Clinical Services]. When asked if she had the documentation of tracking and trending of her concerns, she stated, "No...I notice it on there [the DED record] when I do audits making sure we have not billed at a physician level. I check billing every day...I have no tracking and trending audits of that..." The DED supervisor stated the supervisors and administration had not communicated back to her regarding her concerns.
F. There was no documentation the Quality Assessment Performance Improvement committee reviewed the information regarding patients not being seen by the DED physicians and developed action plans to ensure all patients presenting to the DED seeking medical treatment were adequately examined and treated by the on-call physicians.

3. Review of the facility's Infection Control Policy and Procedure Manual documented, "...To establish preventive, surveillance, and control procedures relating to the inanimate hospital environment, including sterilization and disinfection practices...To monitor findings of any patient care evaluation studies that relate to infection control activities..."

A. Review of the facility's, "Surveillance Methods and Reporting System" policy documented, "...Infection Report Form A...initiated for any of the following conditions:...positive culture...Each month all infections reported and/or discovered and verified by the Infection Control Nurse and are compiled by site, pathogen and occurrence ..."

B. Review of the Infection Control Committee minutes dated July 2011 and October 2011 had no documentation or evidence of tracking and trending of infections for inpatients or outpatients including both healthcare associated and community acquired infections.

C. Review of the facility's Quality Council Minutes dated 7/21/11 and dated 10/20/11 contained no documentation reflecting Healthcare Associated Infections such as:
Aseptic technique practices used in invasive procedures performed outside the operating room: including sterilization of products, central line insertions,
Hand hygiene
Measures specific to prevention of infections caused by antibiotic resistance organisms,
Measures specific to prevention of infections caused by indwelling urinary catheters, tube feedings
Environment and equipment requiring disinfections, antiseptics, and germicides to be used in accordance with manufacturers instructions
Educating patients, visitors, caregivers and staff about infections and community diseases and methods to reduce transmission in the hospital and community.

D. During an interview in the conference room on 11/14/11 at 2:30 PM, the Medical Technologist/Infection Control Officer (MT/ICO) was asked if infections were being tracked and trended. The MT/ICO stated, "...No, I don't track and trend infections..." The MT/ICO was asked if the facility had an Antibiogram that shows what organisms are in the facility and the antibiotics that the organisms are susceptible to. The MT/ICO stated, "...No..." The MT/ICO confirmed a failure to mitigate risks associated with patient infections present on admission due to failure to monitor, track and trend and evaluate infections. The MT/ICO confirmed a failure to mitigate risks contributing to healthcare - associated infections such as handwashing was due to failure to monitor, track and trend and evaluate healthcare practices.

During an interview in the conference room on 11/16/11 at 2:00 PM, the DED supervisor was asked if there was an Infection Control log of DED patients that had a culture completed in the DED and follow performed. The DED supervisor stated, "...no, we do not log it or track it..."


Refer to A748, A749, A750, A0347, A1104 and A1112

Based on, document review, record review and interview, it was determined the hospital's Medical Staff failed to provide care and services with the patient's best health interest in mind. The Medical Staff failed to ensure all patient's who presented to the hospital's Dedicated Emergency Department (DED) received appropriate and adequate medical screening examination (MSE), treatment and care within the hospital's capabilities.

Failure of the Medical Staff to ensure all patients were examined and treated appropriately and adequately placed patients at risk for serious injury, harm and/or death resulting in IMMEDIATE JEOPARDY.

The findings included:

1. The Medical Staff failed to ensure an appropriate and adequate MSE was performed and based on the results of an appropriate and adequate MSE provided treatment to the patients who presented to the hospital's DED seeking care.
Refer to A 0347

Based on document review, record review and interview, it was determined the hospital failed to ensure the medical staff assumed responsibility for the oversight of physicians practicing in the Dedicated Emergency Department (DED) and ensured the practice of medicine was performed in a manner which guaranteed safe, quality medical care to patients presenting to the DED for 14 of 24 (Patients #8, 14, 23, 24, 25, 26, 27, 28, 29, 31, 32, 33, 34 and 35) sampled DED patients.

Failure of the medical staff to provide quality medical care to patients in the DED placed patients coming to the hospital seeking emergency care at risk for serious injury, harm and/or death resulting in IMMEDIATE JEOPARDY.


The findings included:

1. Review of the DED monthly staff meetings dated 6/27/11 documented, "...If a Doctor or Practitioner DOES NOT see a patient, then you must document "not seen" in the space provided on the ER [emergency room] record and logbook. The Doctor/Practitioner is welcome to document whatever he/she wants, but we cannot bill..."

2. Medical record review revealed Patient #8 presented to the DED on 10/23/11 at 2140 with complaints of a migraine headache and nausea. Review of the DED central log dated 10/23/11 documented the patient was "not seen". The patient's DED record documented the patient was not seen. The DED record documented the LPN and RN initiated an assessment, treated and discharged the patient home. On the physical exam/history/orders area of the DED record Physician #1 documented, "...migraine headache...Pt [patient] alert and oriented..." and wrote a diagnosis of "migraine headache" without seeing the patient in the DED.

3. Medical record review for Patient #14 documented the patient presented to the DED on 11/2/11 at 0115 with complaints of epigastric pain. Review of the DED central log dated 11/2/11 documented "not seen". Review of the patient's DED record documented the patient was not seen. The DED record documented the LPN and RN initiated an assessment, treated and discharged the patient home. On the physical exam/history/orders area of the DED record Physician #1 documented, "Abd [abdomen] soft, epigastric tenderness..." and wrote a diagnosis of "Gastritis" without seeing the patient in the DED.

4. Medical record review for Patient #23 documented the patient presented to the DED on 10/16/11 at 1015 with complaints of lower back and left shoulder pain. Review of the DED central log dated 10/16/11 documented "not seen". The patient's DED record documented the patient was not seen. The DED record documented the LPN and RN initiated an assessment, treated and discharged the patient home. On the physical exam/history/orders area of the DED record Physician #1 documented, "...tenderness over left lower lumbar region...right shoulder tenderness..." and wrote a diagnosis of "exacerbation of back pain and shoulder pain" without seeing the patient in the DED.


5. Medical record review for Patient #24 documented the patient presented to the DED on 10/29/11 at 0725 with complaints of headache. Review of the DED central log dated 10/29/11 documented "not seen". Review of the patient's DED record documented the patient was not seen. The DED record documented the LPN and RN initiated an assessment, treated and discharged the patient home. On the physical exam/history/orders area of the DED record Physician #1 documented, "...Pt [patient] alert and oriented pupils PERRLA [Pupils Equal Round Reactive to Light and Accommodation] nonfocal" and wrote a diagnosis of "migraine headache" without seeing the patient in the DED.

6. Medical record review for Patient #25 documented the patient presented to the DED on 10/31/11 at 0335 with complaints of right jaw pain radiating to the ear. Review of the DED central log dated 10/31/11 documented "not seen". Review of the patient's DED record documented the patient was not seen. The DED record documented the LPN and RN initiated an assessment, treated and discharged the patient home. On the physical exam/history/orders area of the DED record Physician #1 documented, "..carious tooth right lower...broke the tooth on his own which is very painful" and wrote a diagnosis "broken right lower molar" without seeing the patient in the DED.

7. Medical record review for Patient #26 documented the patient presented to the DED on 11/9/11 at 2315 with complaints of low back pain. Review of the DED central log dated 11/9/11 documented "not seen". Review of the patient's DED record documented the patient was not seen. The DED record documented the LPN and RN initiated an assessment, treated and discharged the patient home. On the physical exam/history/orders area of the DED record Physician #1 documented, "...mod. [moderate] tenderness over lower lumbar region..." and diagnosed the patient with "exacerbation of low back pain" without seeing the patient in the DED.

8. Medical record review for Patient #27 documented the patient presented to the DED on 11/6/11 at 1215 with complaints of upset stomach. Review of the DED central log dated 11/6/11 documented "not seen". Review of the patient's DED record documented the patient was not seen. The DED record documented the LPN and RN initiated an assessment, treated and discharged the patient home. On the physical exam/history/orders area of the DED record Physician #1 documented, "...upset stomach and mild nausea...abd [abdomen] soft mod [moderate] tenderness over epigastirc..." and wrote a diagnosis of "Gastritis" without seeing the patient in the DED.

9. Medical record review for Patient #28 documented the patient presented to the DED on 11/6/11 at 0100 with complaints of a tooth abscess. Review of the DED central log dated 11/6/11 documented "not seen". Review of the patient's DED record documented the patient was not seen. The DED record documented the LPN and RN initiated an assessment, treated and discharged the patient home. On the physical exam/history/orders area of the DED record Physician #1 documented, "...jaw pain moderate swelling erythemia and pain over left upper jaw molar tooth area" and wrote a diagnosis of "carious tooth left upper with surrounding cellulitis and upper jaw pain..." without seeing the patient in the DED.

10. Medical record review for Patient #29 documented the patient presented to the DED on 10/13/11 at 1700 with complaints of feet pain rated at 10. Review of the DED central log dated 10/13/11 documented "not seen". Review of the patient's DED record documented the patient was not seen. The DED record documented the LPN and RN initiated an assessment, treated and discharged the patient home. On the physical exam/history/orders area of the DED record Physician #1 documented, "...hx [history] of neuropathy...to ER c/o [complains of] bilateral foot pain... states out of Lyrica..." and wrote a diagnosis of "neuropathy pain both feet" without seeing the patient in the DED.

11. Medical record review for Patient #31 documented the patient presented to the DED on 8/18/11 at 0600 with complaints of a headache from being assaulted. The RN documented the patient appeared sedated and had difficulty speaking. A urine sample revealed the patient was positive for barbiturates, benzodiazepine, cannabinoids and opiate. Review of the DED central log documented "not seen" Review of the patient's DED record documented the patient was not seen. The DED record documented the LPN and RN initiated an assessment, treated and discharged the patient. On the physical exam/history/orders area of the DED record Physician #1 wrote "Pt [patient] alert somewhat groggy and somewhat sleepy...PERRLA [Pupils Equal Round Reactive to Light and Accommodation] and wrote a diagnosis of migraine HA [headache]..." without seeing the patient in the DED.

12. Medical record review for Patient #32 documented the patient presented to the DED on 8/14/11 at 0630 with complaints of redness and pain to the eye rating the pain a 10 on a scale of 1-10. The patient suspected a foreign body had lodged in his eye while he was building with wood. Review of the DED central log dated 8/14/11 documented "not seen" Review of the patient's DED record documented the patient was not seen. The DED record documented the LPN and RN initiated an assessment, treated and discharged the patient. On the physical exam/history/orders area of the DED record Physician #1 documented, "...Presented with painful left eye states was building yesterday and some particle material fell into his eye resulting in gross redness left eye - Procedure, under local anesthesia left eye stained...and washed with NS [normal saline] and sterile water, a corneal abrasion was noted left eye patch after application of Tobradex" and wrote a diagnosis dx "S/P [status post] foreign body particle with corneal abrasion" without seeing the patient in the DED.

13. Medical record review for Patient #33 documented the patient presented to the DED on 9/21/11 at 0120 with complaints of back pain. Review of the DED central log dated 9/21/11 documented the patient was "not seen." Review of the patient's DED record documented the patient was not seen. The DED record documented the LPN and RN initiated an assessment, treated and discharged the patient. On the physical exam/history/orders area of the DED record Physician #1 documented, "... mod [moderate] tenderness over left lumbar region..." and wrote a diagnosis of "exacerbation of lumbar pain" without seeing the patient in the DED.

14. Medical record review for Patient #34 documented the patient presented to the DED on 7/31/11 at 2315 with complaints of a migraine headache and anxiety due to the recent death of her husband. Review of the DED log dated 7/31/11 documented the patient was "not seen". On the physical exam/history/orders area of the DED record the time the physician arrived to the DED was left blank. The DED record documented the LPN and RN initiated an assessment, treated and discharged the patient. On the physical exam/history/orders area of the DED record, Physician #2 documented, "...PE [physical exam] unremarkable..." and wrote a diagnosis which included "Anxiety" without seeing the patient in the DED.

14. Medical record review for Patient #35 documented the patient presented to the DED on 7/16/11 at 0300 with complaints of acid reflux, nausea, vomiting and diarrhea. Review of the DED central log dated 7/16/11 documented "not seen" Review of the patient's DED record documented the patient was not seen. The DED record documented the LPN and RN initiated an assessment, treated and discharged the patient. On the physical exam/history/orders area of the DED record Physician #1 documented, "...vomiting and diarrhea + [positive] acid reflux... [abdomen] soft mod [moderate] tenderness..BS [bowel sounds] active mod [moderate] tenderness epigastric area" and wrote a diagnosis "Gastroenteritis" without seeing the patient in the DED.

15. During an interview in the conference room on 11/15/11 at 1:25 PM, the DED Supervisor verified a zero (o) with a strike through the middle in the area for recording the physician's arrival to the ED meant the patient was not seen by the physician. When shown a medical record with this symbol documented but also having documentation indicating an assessment was performed, a diagnosis made and a signature present, the DED Director stated the physician had come to the DED and documented on the patient's record and that the physician was not saying he had seen the patient he was just documenting an assessment. When asked if the patients had been seen by Physician #1, the DED Supervisor stated the DED record documented the patient had not been seen by Physician #1 while the patient was in the DED. The DED Supervisor stated she did not know when Physician #1 wrote the patient assessment and diagnosis. The DED Supervisor stated, "You'll have to ask him that."

16. During a telephone interview from the West Tennessee Health Care Facilities office on 11/17/11 at 8:55 AM, Physician #1, when questioned as to what "not seen" on the patient's DED record meant, Physician #1 stated, "...We do see them from time to time all inpatient and outpatient, when they [nurses] call they are very capable, we have treated them [patients] for years and years, they [nurses] call I may not be there at that time ...they [patients] come in a car pool...nurses call me, say why they are here and has anything changed, they are capable nurses and we go by them. " When asked to clarify when he saw patients to assess them if he did not see them in the ED, Physician #1 stated, "Have existing problem for years and years, seen in hallway, I say, having same problem, [patient] says yes ...nurse calls and says they are here, ask why here, nurses says headache, patient alert and oriented, competent, on my way back, I may see them in hallway ...have been to ER for years and years, have been my patients ... " When the physician was asked if he physically went into the DED to complete the examination, he stated, " Most of the time...". When asked if he saw a patient in the hallway, did he go back later and chart on the patient's DED record, he stated, "Yes, that is what I am saying". When asked when he completed the charting on patients "not seen" he stated, "It may be the next day or some little bit later". When asked how a decision is made regarding treatment, Physician #1 stated, "Well, a chronic problem...we know what is working...problem for years...we have been treating in clinic setting and ER setting...used to the system so much they wont wait here, they want their shot or they will leave, we know what they have...".

Based on policy review, record review and interview, it was determined the hospital failed to ensure that employees provided pharmacy services within the scope of their practice and that drugs were being dispensed only by a licensed pharmacist or physician for 3 of 3 (Patient #23, 28 and 29) dedicated emergency department (DED) sampled patients who were dispensed medications to take home.

The findings included:

1. Review of the hospital's policy, "Prescribing, Dispensing and Administering Drugs in Emergency Room", documented, "...Drugs released from emergency room for take home use must be prepared by the pharmacist or a physician..."

2. Medical record review for Patient #23 documented the patient presented to the DED on 10/17/11 with complaints of lower back pain. The RN documented she dispensed 2 Lortab 10 milligram (mg) tablets for the patient to take home. There was no documentation from a pharmacist or physician.

3. Medical record review for Patient #28 documented the patient presented to DED on 11/6/11 for complaints of a tooth abscess. The RN documented she dispensed 3 tablets of Amoxicillin for the patient to take home. There was no documentation from a pharmacist or physician.

4. Medical record review for Patient #29 documented the patient presented to the DED on 10/13/11 with complaints of feet pain. The RN documented she dispensed 4 Lyrica 150 mg for the patient to take home. There was no documentation from a pharmacist or physician.

During an interview in the conference room on 11/15/11 at 1:25 PM, the DED supervisor was asked who dispensed the medication from the DED to the patients when discharged. The DED supervisor stated, "...Nurses under the direction of the doctor..."








19001

Based on facility policy, observations and interview, it was determined the facility failed to discard outdated medication in the pharmacy and in the dedicated emergency department (DED) for 2 of 2 medication storage areas reviewed.

The findings included:

1. Review of the facility policy, "EXPIRED MEDICATION DISPOSITION" documented, "At the beginning of each month, medications which expired the previous month are pulled off the pharmacy shelves and from the floor stock around the hospital..."

2. Observations in the hospital pharmacy on 11/14/11 at 9:00 AM revealed the following expired mediations on the pharmacy shelves:
One bottle of Theo 24 400 milligram (mg) expiration date 8/10
One bottle of Clorazepate Dipotassium 3.75 mg expiration date 8/2010
One bottle of Phoslo 667 mg expiration date 9/11
Seven single dose packets of Thioridazine hydrochloride 25 mg expiration date 10/11
Five single dose packets of Methyldopa 250 mg expiration 4/11.

3. Observations in the DED on 11/14/11 at 9:40 AM, revealed the following expired medications:
A. In the adult crash cart:
Two multi dose vials of Aminophylline 500 mg expiration date 10/11
Four vials of Verapamil HCL (HydroChloride) 5 mg expiration date 10/11
One bottle of Nitroglycerin 500 ml (milliliters) 100mcq (micrograms)/ml in D5% expiration
date 4/11
Normal Saline 500 ml bag expiration date 9/11.

B. In the courtesy box:
One bottle of Nitroglycerin 500 ml (milliliters) 100 mcq (micrograms)/ml in D5% expiration
date 1/11
Heparin 20,000 units 40 units/ml in a 500 ml bag expiration date 1/11.

C. Stock Cart:
One bottle of Pedilyte expiration date 2/11
One bottle of Pedilyte expiration date 10/11.

D. In the trauma room locked cabinets:
One opened Cetacaine topical anesthetic spray expiration date 6/11
One opened and dated 10/4/11 with an expiration date 7/11 Sensorcaine with Epi (epinephrine) .5%
One bottle of Artificial Tears ointment expiration date 4/11
One bottle of Tropicamide Opthalmic solution .5% expiration date 1/11.

4. During an interview in the pharmacy on 11/14/11 at 9:10 AM, the pharmacist stated, "I don't have a system..."

During an interview in the DED on 11/14/11 at 9:40 AM, Nurse #2 confirmed the medications on the adult crash cart, in the courtesy box and the items on the stock cart were expired.

During an interview in the DED trauma room on 11/14/11 at 9:40 AM, Pharmacy Technician #1 confirmed the medications in the locked cabinet in the trauma room were expired. The Pharmacy Technician stated, "...Yes, they opened an expired vial (Sensorcaine with Epi)..."

Based on policy review, observation and interview, it was determined the Dietary Director failed to ensure the dietary staff followed established policies and procedures for food storage and chemical storage during 3 of 3 days (11/14/11, 11/15/11 and 11/16/11) of observations of the kitchen and dietary storage areas.

The findings included:

1. Review of the facility's "RECEIVING/STORAGE" policy documented, "...PROCEDURE: 3. food will be separately stored from chemicals. 4. Opened food items and leftovers will be labeled, dated and covered to prevent contamination and ensure appropriate use within recommended times..."

Review of the facility's "CLEANING SUPPLIES/HAZARDOUS CHEMICALS" policy documented, "...3. Cleaning supplies and/or hazardous chemicals are stored separately from the food items..."

2. Observations in the kitchen on 11/14/11 at 8:55 AM, revealed the following:
A. In the walk-in refrigerator
2 glasses of orange juice and 2 glasses of milk with no dated label
A lettuce bag open to air revealing 4 heads of lettuce with no date on bag
A pail of cole slaw open with no date
A pail of pimento cheese open with no date
A pail of chicken salad open with no date.

B. In the walk-in freezer:
A bag containing hamburger patty open with no date
A container of cream potato soup open with no date
A bag containing pancakes open with no date
A bag containing fish patty open with no date
A bag containing mixed vegetables open with no date
A bag containing okra open with no date.

C. In the milk refrigerator:
2 half gallon cartons of buttermilk open with no date.

D. A can of Lysol foam cleaner stored on a shelf with the spices over the food preparation table.
A gallon bottle of Clorox liquid stored on the bottom shelf of the clean pots and pan storage rack.
An open bottle of powdered substance cleaner stored on the bottom shelf of the clean pots and pan storage rack.
2 spray bottles of Clorox liquid stored on bottom shelf of the clean pots and pan storage rack.

During an interview in the walk in refrigerator on 11/14/11 at 8:55 AM, Cook Aide #1 was asked about the open food containers not being dated. Cook Aide #1 stated, "...They were suppose to have thrown the orange juice and milk away..." Cook Aide #1 confirmed the food containers were open and not dated.

During an interview in the kitchen on 11/14/11 at 8:55 AM, Cook Aide #1 was asked about the chemicals being stored in the kitchen in the food preparation areas, next to food and clean pots and pans. Cook Aide #1 stated, "...Should not be stored there..."

3. Observations in the kitchen on 11/15/11 at 7:50 AM, revealed the following:
A. In the walk in refrigerator:
A box of citric eggs open with no date
A lettuce bag open to air revealing 4 heads of lettuce with no date on bag.

B. Stock room:
A carton of potato pearls (instant potato) open with no date
A jar of peanut butter jar opened with no date
Rice in a corrugated box with the plastic open and not sealed with no date and scoop laying on top of plastic
A box of creamy wheat hot cereal open with no date
54 corrugated outside shipping boxes on the shelves with food products stored.

C. A gallon bottle of Clorox liquid stored on the bottom shelf of the clean pots and pan storage rack.
An open bottle of powdered substance cleaner stored on the bottom shelf of the clean pots and pan storage rack.
2 spray bottles of Clorox liquid stored on bottom shelf of the clean pots and pan storage rack.

During an interview in the walk in the kitchen on 11/15/11 at 7:50 AM, Cook Aide #1 was asked about the open food containers not being dated. Cook Aide #1 confirmed the food containers were open and not dated.

During an interview in the kitchen on 11/15/11 at 7:50 AM, Cook Aide #1 was asked about the chemicals being stored in the kitchen in the food preparation areas, next to food and clean pots and pans. Cook Aide #1 stated, "...I know that bottle of Clorox is still there, my boss knows it but did not tell me to move it..."

4. Observations in the kitchen on 11/16/11 at 12:50 PM, revealed the following:
A. Stock room
A bag of macaroni open not sealed tightly and with no date
A carton of potato pearls (instant potato) open with no date

B. An open bottle of powdered substance cleaner stored on the bottom shelf of the clean pots and pan storage rack
2 spray bottles of Clorox liquid stored on bottom shelf of the clean pots and pan storage rack

During an interview in the stock room on 11/16/11 at 12:50 PM, the Dietary Manager (DM) was asked about the open food containers not being dated. The DM stated, "...Yes, I see it..." The DM was asked about the storage of chemicals in the food preparation areas and clean pot and pan area. The DM did not comment. The DM was asked about the use of corrugated shipping boxes being used to store food products in the dry stock room. The DM stated, "...I am glad I am retiring soon..."



29706

Based on policy review, document review and interview, it was determined the facility failed to ensure the therapeutic diet manual was approved by the dietitian.

The findings included:

1. Review of the facility's "DIET MANUAL" policy documented, "...The diet manual is reviewed annually and revised as necessary by the registered dietitian...will be signed and dated by the Chief of Staff and the Registered Dietitian..."

2. Review of the facility's "DIETARY MANUAL APPROVAL" signature sheet dated 7/28/11 documented signatures of the Dietary Supervisor, Administrator and Chief Of Staff. There was no documentation the dietician had reviewed and approved the dietary manual.

3. During an interview in the Dietary Manager's (DM) office on 11/14/11 at 9:15 AM, the DM stated, "...No, I don't have a signature sheet of the Registered Dietitian and Medical Staff approval..."



29706

Based on policy review, observation and interview, it was determined the facility failed to ensure food products were stored under appropriate temperature conditions and containers.

The findings included:

1. Review of the facility's "Refrigerator Temps [Temperature]" policy documented, "...To ensure safe and appropriate food temps., the refrigerators are maintained at 40 degrees - 45 degrees..."

Review of the facility's "RECEIVING/STORAGE" policy documented, "...The food items will be stored appropriately to comply with all licensure and regulatory requirements...Food and non-food supplies will be stored under safe, sanitary and secure conditions...Requirements for adequate lighting, ventilation, temperature control...will be observed to ensure compliance with all licensure and regulatory requirements..."

2. Observations in the kitchen walk in refrigerator on 11/14/11 at 8:55 AM, revealed the thermometer located in the front of the refrigerator measured 60 degrees.

During an interview in the walk in refrigerator on 11/14/11 at 8:55 AM, Cook Aide #1 was asked to verify the temperature reading on the thermometer. Cook Aide #1 stated, "Yes, the temperature reads 60 degrees...No, it should not be 60..."

Observations in the kitchen walk in refrigerator on 11/15/11 at 7:50 AM, revealed the thermometer measured 60 degrees.

During an interview in the walk in refrigerator on 11/15/11 at 7:50 AM, Cook Aide #1 confirmed the temperature reading on the thermometer was 60 degrees.

During an interview in the kitchen walk in refrigerator on 11/16/11 at 12:50 PM, the Dietary Manager (DM) stated, "...We got a different thermometer and moved it to the middle of the refrigerator, I think it is high at the door area because of staff having to come in and out to get to the freezer..."

3. Observations in the dry stock room on 11/15/11 at 7:50 AM, revealed 54 corrugated outer shipping boxes being used to store food products.

Observations in the dry stock room on 11/16/11 at 12:50 PM, revealed 54 corrugated outer shipping boxes being used to store food products.

During an interview in the dry stock room on 11/16/11 at 12:50 PM, the DM confirmed the use of corrugated outer shipping boxes were being used to store food products.



29706

Based on policy review, medical record review, observation and interview, the facility failed to provide a sanitary environment to avoid sources and transmission of infections and failed to have a program for the prevention, control, and investigation of infections conducted in accordance with nationally recognized infection control practices or guidelines.

The findings included:

1. The facility failed to follow their policies for the Infection Control Program with the responsibility of the daily functions of the program under the direction of an Infection Control Nurse.
Refer to A 0748

2. The facility failed to develop a system for identifying, reporting, investigating, and controlling infections of patients including both healthcare associated and community acquired infections.
Refer to A 0749

3. The facility failed to maintain an Infection Control log of incidents related to patients who meet CDC (Centers for Disease Control) criteria for requiring isolation precautions during their hospitalization, patients identified by lab culture as colonized or infected with multi drug resistant organisms, incidents related to infections throughout the hospital.
Refer to A 0750

4. The facility failed to ensure established policies and procedures were followed in the dietary department as evidenced by the food storage practices observed in the dietary department.
Refer to A 0620



29706

Based on policy review and interview, it was determined the hospital failed to follow the Infection Control Program's policies and ensure the responsibilities of the daily functions of the Infection Control Program were assigned to a Qualified Infection Control Officer.

The findings included:

1. Review of the hospital's "INFECTION CONTROL PLAN" policy documented, "...III. The Administrator is ultimately responsible for the infection control program. Responsibility is delegated to the Infection Control Nurse to carry out the daily functions of the Infection Control Program. Those functions are described in the Infection Control Nurse job description...VIII. Evaluation of Services Service is evaluated on an on-going (daily) basis with concurrent review of problems by the Infection Control Nurse..."

2. Review of the hospital's "JOB DESCRIPTION AND PERFORMANCE EVALUATION TITLE: Infection Control Nurse" documented, "...PURPOSE: Responsible for implementing and coordinating the program of infection control, prevention, and surveillance approved by the Infection Control Committee...QUALIFICATIONS: 4. Registered Nurse..."

3. During an interview in the conference room on 11/14/11 at 2:30 PM, the Medical Technologist/Infection Control Officer was asked are you a nurse. The Medical Technologist/Infection Control Officer stated, "...No, I am a Medical Technologist...".

During an interview in the conference room on 11/15/11 at 8:28 AM, the Administrative Assistant stated, "...We don't have an Infection Control Nurse, we know we have a problem. We know we need to have a nurse...".



29706

Based on policy review, medical record review and interview, it was determined the hospital failed to develop a system for identifying, reporting, investigating, and controlling infections of patients including both healthcare associated and community acquired infections.

The findings included:

1. Review of the hospital's "INFECTION CONTROL POLICY AND PROCEDURE MANUAL TITLE: OBJECTIVES" policy documented, "...5. To establish preventive, surveillance, and control procedures relating to the inanimate hospital environment, including sterilization and disinfection practices...11. To monitor findings of any patient care evaluation studies that relate to infection control activities..."

Review of the facility's, "Surveillance Methods and Reporting System" policy documented, "...Infection Report Form A...initiated for any of the following conditions:...positive culture...Each month all infections reported and/or discovered and verified by the Infection Control Nurse and are compiled by site, pathogen and occurrence..."

Medical record review for Resident #30 documented an admission date of 7/5/11 with diagnoses of Aspiration Pneumonia, Hypoxia and UTI (Urinary Tract Infection). Review of the UA [urinalysis] culture obtained 7/6/11 and reported 7/9/11 documented, "...Proteus Mirabilis...". Review of the wound culture obtained 7/6/11 and reported 7/9/11 documented, "...Proteus Mirabilis...". Review of the Complete Blood Count (CBC) report dated 7/6/11 documented, " WBC [white blood count] 26.7 H [high]...". Review of the medical record had no documentation of follow up UA or CBC to evaluate the effectiveness of treatment or documentation of the effectiveness of treatment.

During an interview in the conference room on 11/14/11 at 2:30 PM, the Medical Technologist/Infection Control Officer (MT/ICO) was asked are infections being tracked and trended. The MT/ICO stated, "...No, I don't track and trend infections...". The MT/ICO was asked does the facility have an Antibiogram that shows what organisms are in your facility and the antibiotics that the organisms are susceptible to. The MT/ICO stated, "...No...". The MT/ICO confirmed the failure to mitigate risks associated with patient infections present on admission was due to failure to monitor, track and trend and evaluate infections. The MT/ICO confirmed the failure to mitigate risks contributing to healthcare - associated infections such as handwashing was due to failure to monitor, track and trend and evaluate healthcare practices.

2. Review of the facility's "CLEANING AND DECONTAMINATING BLOOD SPILLS" policy documented, "...All spills of blood and blood-contaminated fluids should be promptly cleaned up using a germicide that is mycobactericidal or a solution of sodium hypochlorite (bleach) in 1:10 dilution WHILE WEARING GLOVES..."

Review of the facility's cleaning product label "DMQ" documented, "...Bactericidal and Virucidal...Preliminary cleaning is required for heavily soiled areas...Apply with a mop, cloth or spray device. Treated surface must remain wet for 10 minutes..."

During an interview in the DED on 11/14/11 at 9:40 AM, LPN #2 was asked what does she use to clean the stretchers after patient use. The LPN #2 stated, "...We use DMQ, mixed by housekeeping in this bottle...I spray it then wipe it off...I am not aware of having to leave the surface wet (with cleaner) for any length of time...".
LPN #2 was asked how does she clean the glucometer. LPN #2 stated, "...wipe it down with DMQ and dry with a towel...no, don't allow to air dry...no, don't know about contact time to kill organisms...". LPN #2 was asked how does she clean up a blood spill. LPN #2 stated, "...use DMQ that is in the spill kit...".

During an interview in the conference room on 11/14/11 at 2:15 PM, the Housekeeping Manager was asked how is staff to clean up a blood spill. The Housekeeping Manager stated, "...Have DMQ in the spill kit, spray it down...". The Housekeeping Manager was asked to review the DMQ label and the facility's cleaning and decontaminating blood spill policy. The Housekeeping Manager confirmed DMQ did not meet the facility's cleaning and decontaminating blood spill policy. The Housekeeping Manager was asked do they clean the environment differently when a patient has Clostridium Difficle. The Housekeeping Manager stated, "No, we don't clean any different...Use DMQ or Clean on the Go...". The Housekeeping Manager was asked if DMQ or Clean on the Go had Clostridium Difficle listed as an organism it kills. She stated, "No".

During an interview in the conference room on 11/14/11 at 2:30 PM, the MT/ICO was asked how do you clean up a blood spill. The MT/ICO stated, "I don't know, to be honest I'd have to get the policy and procedure". The MT/ICO was asked are you aware of the cleaning products housekeeping uses. The MT/ICO stated, "...No...".

3. Review of the facility's "Infection Control Program" failed to address Healthcare Associated Infections such as:
Aseptic technique practices used in invasive procedures performed outside the operating room: including sterilization of products, central line insertions.
Hand hygiene.
Measures specific to prevention of infections caused by antibiotic resistance organisms, Measures specific to prevention of infections caused by indwelling urinary catheters, tube feedings.
Environment and equipment requiring disinfections, antiseptics, and germicides to be used in accordance with manufacturers instructions.
Educating patients, visitors, caregivers and staff about infections and community diseases and methods to reduce transmission in the hospital and community.

Observations in the Dedicated Emergency Department on 11/14/11 at 9:40 AM, revealed no signage in the DED or common areas about flu or handwashing.

Review of the Infection Control Committee minutes dated July 2011 and October 2011 had no documentation of Healthcare Associated Infections.

During an interview in the conference room on 11/14/11 at 2:30 PM, the MT/ICO was asked are infections being tracked and trended. The IMT/ICO stated, "...No, I don't track and trend infections...".



29706

Based on interview, it was determined the facility failed to maintain an Infection Control log of incidents related to patients who meet CDC (Centers for Disease Control) criteria for requiring isolation precautions during their hospitalization, patients identified by lab culture as colonized or infected with multi drug resistant organisms (MDRO), incidents related to infections throughout the hospital.

The findings included:

1. There was no documentation of an Infection Control log of incidents related to patients who meet the CDC criteria for requiring isolation precautions during their hospitalization. There was no documentation of a log of patients identified by lab culture as colonized or infected with multi drug resistant organisms (MDRO), incidents related to infections throughout the hospital including the dedicated emergency department patients.

2. During an interview in the conference room on 11/14/11 at 2:30 PM, the Medical Technologist/Infection Control Officer (MT/ICO) asked are infections being tracked and trended. The MT/ICO stated, "...No, I don't track and trend infections..."

During an interview in the conference room on 11/16/11 at 2:00 PM, the Dedicated Emergency Department (DED) supervisor was asked is there an Infection Control log of DED patients that have a culture completed in the DED and follow up. The DED supervisor stated, "...no, we do not log it or track it..."




29706

Based on review of the Rules and Regulations of the Tennessee Board of Nursing, policy review, medical record review and interview, the facility failed to ensure staff providing care in the Dedicated Emergency Department (DED) followed policies for patient assessment and care, failed to ensure qualified staff provided assessments, medical screening treatment and stabilization and failed to ensure staff working in the DED possessed the required skills to treat patients in the DED.

Failure to ensure staff followed policies and were qualified exposed all patients coming to the hospital seeking emergency care to the potential for serious injury, harm and/or death resulting in IMMEDIATE JEOPARDY.


The findings included:

1. The hospital failed to provide medical staff oversight to ensure protocols were in place for non-physician personnel to use in the DED to determine if an emergency medical condition existed and failed to ensure all patients received an appropriate medical screening exam, treatment and stabilization, prior to discharge.
Refer to A1104

2. The facility failed to ensure the staff working in the DED possessed the required skills and qualifications to perform on-going assessments for patients presenting to the DED.
Refer to A1112

Based on policy review, document review, record review and interview, it was determined the medical staff failed to assume responsibility and ensure all patients presenting to the Dedicated Emergency Department (DED) seeking medical attention received an appropriate medical screening examination (MSE) to determine if an emergency medical condition existed. Failure to provide medical staff oversight to ensure adequate assessments were performed lead to patients being treated and released without having determined the source of their illness or injury; therefore, the appropriateness of the treatment and disposition could not be determined due to the lack of definitive evidence an emergency medical condition did or did not exist, thereby, exposing all patients to the potential for serious injury, harm and/or death resulting in IMMEDIATE JEOPARDY for 16 of 24 (Patients #8, 11, 14, 23, 24, 25, 26, 27, 28, 29, 31, 32, 33, 34, 35 and 36) sampled DED patients.

The findings included:

1. Review of the hospital's By-Laws Rules and Regulations addendum dated 1/17/07 documented, "...All patients presented to the Emergency Room will be medically screened by qualified medical personnel to determine whether an emergency condition exists. This screening may be done by a Physician, Nurse Practitioner, Physician's Assistant, or a qualified Registered Nurse with advanced training. This may include but is not limited to, (ACLS, PALS, BLS) and/or emergency room experience."

Review of the personnel files for the 4 RN's identified as responsible for performing MSE revealed the files did not contain evidence of any criteria having been evaluated and found to be met or evidence that the RN had been deemed qualified to perform this function.

2. Review of the hospital's policy, "Emergency Medical Treatment", documented, "Any individual who comes to the emergency department and requests examination or treatment for a medical condition is entitled to and will receive an appropriate medical screening examination...The medical screening examination is an ongoing process based on the patient's needs and continue until the patient is either stabilized or appropriately transferred...How to Provide the Medical Screening Examinations...The medical screening examination shall include both a generalized assessment and a focused assessment...A medical screening examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation prior to discharge or transfer along with documentation of the process...When non-physician personnel perform the medical screening examinations, screening protocols that outline the examination and/or diagnostics workup required to determine if an emergency medical condition exits should be developed and approved by the hospital's medical staff. These protocols will normally be complaint specific and will be limited to those presented complaints that lend themselves to screening by such non-physician personnel... Emergency medical condition... A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and/or symptoms of substance abuse)..."

During an interview on 11/9/11 at 9:00 AM, when questioned if the ED RNs who performed the MSE used a complaint specific protocol to determine if an emergency medical condition existed the ED Supervisor stated, "We do not have the protocols"

3. Review of the hospital's "Medical Screening Exam" form documented a check box format numbered 1 - 20 with an area on the last page to write additional notes. The check boxes were titled, General, Nutrition, Psychosocial, Functional Status, Fall Risk Assessment, Barrier to Learning, Pain Assessment, Respiratory, Cardiovascular, Endocrine, Neurological, Gastrointestinal, GU/GYN [genitourinary/gynecological], Integumentary, Eyes, Musculoskeletal, Suspected Abuse, Suicidal Risk, Past Medical History and Past Surgeries.

4. Review of the DED patient log revealed patients # 8, 11, 14, 23, 24, 25, 26, 27, 28, 29, 31, 32, 33, 34, 35 and 36 were documented as not having been seen by the physician.

5. Medical record review for Patient #31 documented the patient presented to the DED on 8/18/11 at 0600 complaining of a headache from being assaulted. The triage nurse documented at 0600 the patient stated she has had a migraine headache for 3 days and experienced 3 seizures that morning prior to coming to the DED. Review of the MSE form dated 8/18/11 at 0605 revealed the RN documented the patient complained of head pain rating a 10 on a scale of 1-10 with 10 being the most painful. The RN documented "the patient appears sedated, some difficulty with speech... friend states she fell on everything..." On page 3 of the form under Nurses Notes the Licensed Practical Nurse (LPN) documented at 0650, "Pt [Patient] states her 'daughter and the man that brought me here hit me' ...abrasion noted to bridge of nose... 0656 requested from patient a urine specimen, patient to BR [bathroom] per self, when pt exited BR she was carrying a urine specimen cup with clear liquid inside, Patient states 'I tried to pee but can't' asked pt if she could void at all in a few minutes, Pt states 'If I could drink some water maybe I could', pt removed lid from specimen cup and drank the contents therein 0710 I&O [In & Out} cath catherization performed to obtain urine specimen..." There was no documentation of further assessment of the patient to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. There was no documentation the DED physician had examined the patient. Review of the results of the urine sample documented the patient was positive for barbiturates, benzodiazepine, cannabinoids and opiate. Despite the ED form documenting the patient was not seen, a diagnosis of migraine headache and multiple illicit substance use was documented on the form. The patient was administered Toradol IM at 0710 and was discharged home at 0835. There was no documentation of the patient's chief complaints which brought her to the DED, including seizures, falls, assaults and illicit drug use.

6. Medical record review for Patient #32 documented the patient presented to the DED on 8/14/11 at 0630 with complaints of pain and redness in the left eye. The triage nurse documented at 0630 the patient stated he was building a building and had a possible foreign body in his eye. The patient rated his eye pain a 6 on a scale of 1-10 with 10 being the most painful. Review of the MSE form dated 8/14/11 at 0630 revealed the RN documented the patient stated he had been building with wood the day before and suspected wood had gotten into his eye. On the MSE form in the area for pain assessment the RN documented the patient had pain in the left eye rating a 6. There was no further documentation of an assessment of the patient's eye and the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. There was no documentation the DED physician examined the patient's eye. Despite the DED form documentation the patient was not seen, a diagnosis of foreign body with corneal abrasion was documented on the form. The patient was administered eye ointment at 0640 and was discharged home with an eye patch at 0705. There was no documentation of referral to an eye specialist for evaluation/treatment of the left eye injury.

7. Medical record review for Patient #8 documented the patient arrived by ambulance to the DED on 10/23/11 at 2140 with complaints of a migraine headache rating the pain an 8 on a scale of 1-10 with 10 being the most painful. The patient also complained of nausea. Review of the MSE form dated 10/23/11 at 2140 revealed the RN documented under the area for pain assessment the patient had a headache rating the pain an 8 and "seen in ER [DED] earlier today, given Nubain 5 mg with some relief...". The RN documented the patient had been treated by emergency medical services (EMS) with intravenous Zofran and Nubain Intramuscularly (IM) prior to this hospital visit at 1830. There was no further documentation of an assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. There was no documentation the DED physician had examined the patient. Despite the ED form documenting the patient was not seen, a diagnosis of migraine headache was documented on the form. The patient was administered Nubain and Phenergan Intravenously (IV) at 2145 and was discharged at 2230.

8. Medical record review for Patient #11 documented the patient was admitted to the DED on 11/6/11 at 1820 with complaints of a headache rating a 10 on a scale of 1 - 10 with 10 being the most painful. The patient also complained of nausea. The RN documented the patient had been treated with Nubain and Phenergan Intramuscularly (IM) prior to this hospital visit and now the patient complained the headache and nausea were worse. Review of the MSE form dated 11/6/11 at 1825 revealed the RN documented the patient had a headache rating a "10/10" There was no further documentation of an assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific form to rule out an emergency medical condition. There was no documentation the DED physician had examined the patient. Despite the ED form documenting the patient was not seen, Nubain and Phenergan IM were administered at 1835 and the patient was discharged home at 1850.

9. Medical record review for Patient #14 documented the patient was admitted to the DED on 11/2/11 at 0115 with complaints of epigastric pain rating a 6 on a scale of 1-10 with 10 being the most painful. Review of the MSE form dated 11/02/11 at 0120 revealed the RN documented in the area for pain assessment the patient had epigastric pain rating a 6, the pain started one hour ago and the pain was made better with pressure to the area. There was no further documentation of an assessment of the pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. There was no documentation the DED physician examined the patient. Despite the ED form documenting the patient was not seen, a diagnosis of gastritis was documented on the form. The patient was administered Reglan, Pepcid and a gastrointestinal (GI) cocktail by mouth at 0135 and was discharged at 0200.

10. Medical record review for Patient #23 documented the patient was admitted to the DED on 10/16/11 at 1015 with complaints of lower back and left shoulder pain rating a 9 on a scale of 1-10 with 10 being the most painful. Review of the MSE form dated 10/11/11 at 1020 revealed the RN documented in the area for pain assessment the patient had low back and left shoulder pain rating a 9. There was no further documentation of an assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. There was no documentation the DED physician had examined the patient. Despite the ED form documenting the patient was not seen, a diagnosis of Exacerbation of low back pain and right shoulder pain (even though the patient complained of left shoulder pain) was documented on the form. The patient was administered Vistaril IM at 1020 and was discharged home at 1030.

On 10/17/11 at 0330 Patient #23 presented a second time to the DED with complaints of lower back and left shoulder pain rating a 6 on a scale of 10 with 10 being the most painful. The MSE form revealed the RN documented in the area for pain assessment the patient had left shoulder pain rating a 6. The form documented the patient stated he had run out of pain medication earlier that day. The physician was notified and ordered 2 Lortab 10 milligram tablets to be dispensed to the patient to take home. There was no further assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. There was no documentation the DED physician had examined the patient. Despite the ED form documenting the patient was not seen, the patient was dispensed two 10 milligram (mg) Lortab at 0335 by the RN and discharged home at 0400.

11. Medical record review for Patient #24 documented the patient was admitted to the DED on 10/29/11 at 0725 with complaints of headache rating 6 on a scale of 1-10 with 10 being the most painful. The patient also complained of nausea. The RN documented the patient had taken Imitrex and Zofran prior to arrival in the DED at 0300. Review of the MSE form dated 10/29/11 at 0730 revealed the RN documented in the area for pain assessment the patient complained of a headache rating the pain a 6, sound and light made the pain worse and Imitrex helped the pain some. There was no further documentation of an assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. There was no documentation the DED physician had examined the patient. Despite the ED form documenting the patient was not seen, a diagnosis of migraine headache was documented on the form. The patient was administered Nubain and Phenergan IM at 0750 and discharged home at 0805.

12. Medical record review for Patient #25 documented the patient presented to the DED on 10/31/11 at 0335 with complaints of right jaw pain radiating to the ear. The pain was rated a 10 on a scale of 1 - 10 with 10 being the most painful. Review of the MSE form dated 10/31/11 at 0335 revealed the RN documented in the area for pain assessment the patient complained of right back molar and right ear pain rating a "10+" and the patient had tried oragel and Motrin without any relief. There was no further assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. There was no documentation the DED physician had examined the patient. Despite the ED form documenting the patient was not seen, a diagnosis of broken right lower molar was documented on the form. The patient was administered Nubain and Phenergan IM at 0350 and it was repeated at 0420. The patient was discharged home at 0545. There was no referral to a Dentist for evaluation/treatment of right jaw pain.

13. Medical record review for Patient #26 documented the patient presented to the DED on 11/9/11 at 2315 with complaints of lower back pain rating the pain a 9 on a scale of 1 -10 with 10 being the most painful. Review of the MSE form dated 11/9/11 at 2320 revealed the RN documented the patient complained of low back pain rating the pain a 9 and a history of chronic low back pain. There was no further assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the DED physician had examined the patient. Despite the ED form documenting the patient was not seen, a diagnosis of exacerbation of low back pain was documented on the form. The patient was administered Nubain, Phenergan and Robaxin IM at 2340 and was discharged home at 2358.

14. Medical record review for Patient #27 documented the patient presented to the DED on 11/6/11 at 1215 with complaints of upset stomach. Review of the MSE form dated 11/6/1/1 at 1220 revealed the RN documented on the MSE form the patient complained of nausea,vomiting and diarrhea since mid-night and had experienced these same symptoms 2 weeks ago. The RN documented on the MSE form the patient experienced abdominal pain when vomiting, lumbar pain and had a sore throat from vomiting. On the MSE form in the area by pain assessment the RN documented "denies pain" There was no further assessment of the patient's symptoms to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. There was no documentation the DED physician assessed the patient. The patient was administered Pepcid and a "GI Cocktail" at 1240 and was was discharged home at 1300.

15. Medical record review for Patient #28 documented the patient presented to the DED on 11/6/11 at 0100 with complaints of an abscessed tooth. Review of the MSE form dated 11/6/11 at 0105 revealed the RN documented in the area for pain assessment the patient complained of right jaw pain rating the pain a 10. There was no documentation of an assessment of the patient's mouth, jaw and teeth. There was no documentation of further assessment to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. There was no documentation the DED physician examined the patient. Despite the ED form documenting the patient was not seen, a diagnosis of gastritis was documented on the form. The patient was administered Nubain and Phenergan IM at 0115 and was discharged home at 0130. There was no referral to a Dentist for evaluation/treatment of complaints of an abscessed tooth.

16. Medical record review for Patient #29 documented the patient was admitted to the DED on 10/13/11 at 1700 with complaints of feet pain and complained he was out of his medication Lyrica. Review of the MSE form dated 10/13/11 at 1655 revealed the RN documented in the area of pain assessment the patient complained of a pain of rating 10. Documented under Nurses Notes was the patient's complaints of feet pain, history of neuropathy, out of his medication and history of exposure to Agent Orange. There was no documentation of further assessment of the pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. There was no documentation the DED physician had examined the patient. Despite the ED form documenting the patient was not seen, a diagnosis of neuropathic pain both feet was documented on the form. The patient was dispensed four Lyrica 150 mg by the RN (no time documented) and was discharged at 1730.

17. Medical record review for Patient #33 documented the patient presented to the DED on 9/21/11 at 0120 with complaints of back pain. Review of the triage note dated 9/21/11 at 0120 documented the patient complained of back pain rating the pain a 10 on a scale of 1-10 with 10 being the most painful. Review of the MSE form dated 9/21/11 at 0124 revealed the RN documented the patient complained of back pain with a pain scale rating of 10. There was no further documentation of an assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. There was no documentation the DED physician examined the patient. Despite the ED form documenting the patient was not seen, a diagnosis of exacerbation of back pain was documented on the form. The patient was administered Nubain and Phenergan IM at 0145 and was discharged home at 0200.

18. Medical record review for Patient #34 documented the patient was admitted to the DED on 7/3/11 at 2315 with complaints of a migraine with pain rated 9 on a scale of 1-10 with 10 being the most painful. The patient also complained of anxiety due to the recent death of her ex-husband. The RN documented the patient had taken Imitrex early that day without pain relief. There was no documentation of further assessment of the patient's pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. The RN documented she contacted the physician who gave an order for IM medication. Despite the ED log documenting the patient was not seen and the form being blank in the area for time of physician arrival, a diagnosis of cephalgia and anxiety was documented. The patient was administered Nubain and Phenergan IM at 2330 and discharged home at 2345.

19. Medical record for patient #35 documented the patient was admitted to the DED on 7/16/11 at 0300 with complaints of acid reflux, nausea, vomiting and diarrhea with abdominal pain rating the pain a 7 on a scale of 1-10 with 10 being the most painful. The triage nurse documented the patient stated he had recently drank spring water that smelled funny and the symptoms had been present for 5 days since that time. Review of the MSE form dated 7/15/11 at 0300 revealed the RN documented in the area for pain assessment the patient complained of abdominal pain for 5 days, rating the pain a 7, pain is worse when the patient drinks cold water, nothing relieves the patient's pain and the patient had not eaten for 5 days. The RN documented the patient complained of "smothering" when in the supine position and has had several episodes of incontinence. Nurses Notes documented the patient was seen in the emergency department at another hospital the last 2 nights for the same complaint. The physician was contacted and gave orders for treatment. There was no documentation of further assessment of the patient to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol in order to determine if an emergency medical condition existed. There was no documentation the DED physician had examined the patient. Despite the ED form documenting the patient was not seen, a diagnosis of gastroenteritis was documented on the form. The patient was administered Zofran IV at 0330, Flagyl IV at 0335 and Cipro IV at 0400 The RN dispensed (3) Cipro 500 mg and (3) Flagyl 250 mg at 0445. The patient was discharged home at 0500. The patient's complaints of "smothering" when in the supine position and incontinence were not assessed. There was no documentation that patient was referred to attending physician for continued complaints.


20. Medical record review for Patient #36 documented the patient presented to the DED on 9/13/11 at 0350 with complaints of right hip and leg pain rating the pain a 10 on a scale 1-10 with 10 being most painful. Review of the MSE form revealed the RN documented in the area for pain assessment the patient complained of right lower leg pain rating the pain a 10. There was no further documentation of an assessment of the patient's leg and pain to determine if an emergency medical condition existed. There was no documentation the RN used a complaint specific protocol to determine if an emergency medical condition existed, There was no documentation the DED physician had examined the patient. Despite the ED form documenting the patient was not seen, Demerol, Phenergan and Benadryl IM were administered at 0415 and was discharged at 0435.




19001

Based on review of the Tennessee Nursing Board, policy review record review and interview, it was determined the hospital failed to ensure the staff of the dedicated emergency department (DED) possessed the skills and qualifications to perform duties in the emergency department for 12 of 24 (Patients #8, 11, 14, 23, 24, 25, 26, 27, 31, 32 and 33 and 36) sampled Dedicated Emergency Department (DED) patient records.

Failure of the hospital to ensure the staff were qualified and possessed the skills to perform assigned duties in the DED exposed patients coming to the hospital seeking emergency care at risk for serious injury, harm and/or death resulting in IMMEDIATE JEOPARDY.

The findings included:

1. Review of the Rules of The Tennessee Board of Nursing documented, "Standards of Nursing Practice for the Registered Nurse ...The Registered Nurse shall ...Conduct and document nursing assessments ...Evaluate the responses of individuals ...Communicate accurately in writing and orally with recipients of nursing care and other professionals ...Delegate to another only those nursing measures which that person is prepared or qualified to perform.."
Review of the Tennessee Board of Nursing Position Statements reaffirmed February 2009 documented, "It is apparent from these rules the interpretation of the standard of care for the licensed practical nurse in terms of assessment is that the individual is not prepared educationally in the basic vocational program with the requisite scientific skills to expand his or her practice to assessment of patients, formulation of a plan of care, or evaluation of the plan of care developed by the registered nurse..."


2. Review of the hospital's By-Laws Rules and Regulations addendum dated 1/17/07 documented, "...All patients presented to the Emergency Room will be medically screened by qualified medical personnel to determine whether an emergency condition exists. This screening may be done by a Physician, Nurse Practitioner, Physician's Assistant, or a qualified Registered Nurse with advanced training. This may include but is not limited to, (ACLS, PALS, BLS) and/or emergency room experience."

Review of the personnel files for the 4 RN's identified as responsible for performing MSE revealed the files did not contain evidence of any criteria having been evaluated and found to be met or evidence that the RN had been deemed qualified to perform this function.


3. Review of the hospital's policy, "Emergency Medical Treatment", documented, ".. When non-physician personnel perform the medical screening examinations, screening protocols that outline the examination and/or diagnostics workup required to determine if an emergency medical condition exits should be developed and approved by the hospital's medical staff. These protocols will normally be complaint specific and will be limited to those presented complaints that lend themselves to screening by such non-physician personnel... Emergency medical condition... A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and/or symptoms of substance abuse)...A medical screening examination is not an isolated event. It is an on-going process. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. There should be evidence of this evaluation prior to discharge or transfer along with documentation of the process... "


Review of the hospital's policy, "Emergency Room Policy and Procedure Manual, Admissions/Assessments", documented, "...Assessment of Emergency Department patients will begin at the time of presenting to department...Designated time frames for reassessment are ongoing throughout the ER [dedicated emergency department] visit...All patients presenting to the ER will be assessed and triaged into the following categories...Each patient will be assessed upon arrival to the ER. The triage assessment will be performed by a competent nurse..."

4. Medical record review for Patient #8 documented the patient was admitted to the DED on 10/23/11 at 2140 with complaints of migraine headache rating a 8 on a scale of 1-10 with 10 being the most painful. The patient also complained of nausea. The RN documented the patient had been treated by emergency medical services with intravenous Zofran and Nubain IM prior to this hospital visit at 1830. The Licensed Practical Nurse (LPN) administered Nubain IV and Phenergan IM at 2145. There was no documentation the RN performed a follow-up assessment and continued monitoring of the patient's pain and nausea. At 2230 the LPN documented the patient was improved and discharged the patient home. There was no documentation the RN assessed the patient to determine if the patient had been stabilized prior to being discharged.

5. Medical record review for Patient #11 documented the patient was admitted to the DED on 11/6/11 at 1820 with complaints of a headache rating a 10 on a scale of 1 - 10 with 10 being the most painful. The patient also complained of nausea. The RN initiated a MSE at 1825. The patient was administered Nubain and Phenergan IM at 1835. There was no documentation the RN performed a follow-up assessment and continued monitoring of the patient's pain and nausea. At 1850 the Licensed Practical Nurse (LPN) documented the patient was stable and discharged the patient home. There was no documentation the RN assessed the patient to determine if the patient had been stabilized prior to being discharged home.

6. Medical record review for Patient #14 documented the patient was admitted to the DED on 11/2/11 at 0115 with complaints of epigastric pain rating a 6 on a scale of 1-10 with 10 being the most painful. The LPN performed the triage assessment at 0115. The RN initiated the MSE at 0120. The LPN administered Reglan, Pepcid and a gastrointestinal (GI) cocktail by mouth at 0135. There was no documentation the RN performed a follow-up assessment and continued monitoring of the patient's pain. The LPN documented the patient was stable and discharged the patient home at 0200. There was no documentation the RN assessed the patient prior to the patient being discharged home.

7. Medical record review for Patient #23 documented the patient was admitted to the DED on 10/16/11 at 1015 with complaints of lower back and left shoulder pain rating a 9 on a scale of 1-10 with 10 being the most painful. The RN initiated the MSE at 1020. The LPN administered Vistaril IM at 1020. There was no documentation the RN performed a follow-up assessment and continued monitoring of the patient's pain. The LPN documented the patient was improved and discharged the patient home at 1030. There was no documentation the RN assessed the patient prior to the patient being discharged home.

8. Medical record review for Patient #24 documented the patient was admitted to the DED on 10/29/11 at 0725 with complaints of headache pain rating 6 on a scale of 1-10 with 10 being the most painful. The patient also complained of nausea. The RN initiated the MSE at 0730. The LPN administered Nubain and Phenergan IM at 0750. There was no documentation the RN performed a follow-up assessment and continued monitoring of the patient's pain. The LPN documented the patient was stable and discharged the patient home at 0805. There was no documentation the RN assessed the patient prior to the patient being discharged home.

9. Medical record review for Patient #25 documented the patient presented to the DED on 10/31/11 at 0335 with complaints of right jaw pain radiating to the ear. The pain was rated a 10 on a scale of 1-10 with 10 being the most painful. The LPN performed the triage assessment at 0335. The RN initiated the MSE at 0335. The LPN administered Nubain and Phenergan IM at 0350 and repeated it at 0420. There was no documentation the RN performed a follow-up assessment and continued monitoring of the patient's pain. The LPN documented the patient was stable and discharged the patient home at 0545. There was no documentation the RN assessed the patient prior to the patient being discharged home.

10. Medical record review for Patient #26 documented the patient presented to the DED on 11/9/11 at 2315 with complaints of lower back pain rating the pain a 9 on a scale of 1 -10 with 10 being the most painful. The LPN performed the triage assessment at 2315. The RN initiated the MSE at 2320. The LPN administered Nubain, Phenergan and Robaxin IM at 2340. There was no documentation the RN performed a follow-up assessment and continued monitoring of the patient's pain. The LPN documented the patient was stable and discharged the patient home at 2358. There was no documentation the RN assessed the patient prior to being discharged home.

11. Medical record review for Patient #27 documented the patient presented to the DED on 11/6/11 at 1215 with complaints of upset stomach, vomiting, sore throat and lumbar pain. The LPN performed the triage assessment at 1215. The RN initiated the MSE at 1220. The LPN administered Pepcid and a "GI Cocktail" at 1240. There was no documentation the RN performed a follow-up assessment and continued monitoring of the patient's pain and vomiting. The LPN documented the patient was stable and discharged the patient home at 1300. There was no documentation of a RN assessed the patient prior to being discharged home.

12. Medical record review for Patient #31 documented the patient presented to the DED on 8/18/11 at 0600 complaining of a headache from being assaulted. The LPN performed the triage assessment at 0600. The RN initiated the MSE at 0605 and documented the patient appeared sedated and had difficulty speaking. Results of the urine sample documented the patient was positive for barbiturates, benzodiazepine, cannabinoids and opiate. The LPN administered Toradol IM at 0710. There was no documentation the RN performed a follow-up assessment and continued monitoring of the patient's mental status and pain. The LPN documented the patient was stable and discharged the patient home at 0835. There was no documentation the RN assessed the patient prior to being discharged home.

13. Medical record review for Patient #32 documented the patient presented to the DED on 8/14/11 at 0630 with complaints of pain and redness in the left eye due to a possible foreign body in the eye. The patient rated the pain a 10 on a scale of 1 -10 with 10 being the most painful. The RN documented she initiated the MSE at 0630. There was no documentation the RN performed an assessment of the patient's eye while initiating the MSE. The LPN administered eye drops and eye ointment to the patient at 0640. There was no documentation the RN performed a follow-up assessment and continued monitoring of the patient's eye and pain. The LPN instructed the patient to wear an eye patch, determined the patient was stable and discharged the patient at 0705. There was no documentation the RN assessed the patient prior to being discharged home.

14. Medical record review for Patient #33 documented the patient presented to the DED on 9/21/11 at 0120 with complaints of back pain rating the pain a 10 on a scale of 1-10 with 10 being the most painful. The LPN performed the triage assessment at 0120. The RN initiated the MSE at 0124. The LPN administered Nubain and Phenergan IM at 0145. There was no documentation the RN performed a follow-up assessment and continued monitoring of the patient's pain. The LPN documented the patient was stable and discharged the patient at 0200. There was no documentation the RN assessed the patient prior to being discharged home.

15. Medical record review for Patient #36 documented the patient presented to the DED on 9/13/11 at 0350 with complaints of hip and leg pain rating the pain a 10 on a scale of 1-10 with 10 being the most painful. The RN initiated the MSE at 0355. The LPN administered Demerol, Phenergan, and Benadryl IM at 0415. There was no documentation the RN performed a follow-up assessment and continued monitoring of the patient's pain. The LPN documented the patient was improved and discharged the patient at 0435. There was no documentation of the RN assessed the patient prior to being discharged home.


16. During an interview in the conference room on 11/16/11 at 8:50 AM, the ED night supervisor was asked if Patient #26 was seen by the physician she stated, " I wasn't aware he wasn't seen, I go assess patient and go back to the floor if it is not a critical patient " When asked if she worked the floor at night in addition to working as night supervisor in the ED, she stated, "Yes." The surveyor asked if the LPN on duty, conducted the discharge assessment, the night supervisor stated, "Vital signs are done by the LPN." When asked who determines the patient is stable for discharge, she stated, "I assume the doctor tells give meds and discharge home ...LPN discharges...".








19001