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Based on observations, interviews and document review, the facility failed to ensure nursing staff administered patient medications according to physician order and per the recommended dosing guidelines. Additionally, the facility failed to ensure nursing staff safely handled multiple-dose medications to reduce the risk of infection associated with the medication administration.

This failure created a potential for negative patient outcomes related to unsafe medication administration.

FINDINGS:

POLICY

According to the policy, Pediatric Medication Administration, the Registered Nurse (RN) reviews each new medication order entered by the provider/pharmacist for accuracy and completeness, including correct dose. The right medication will be administered in the right dosage, at the right time by the right route to the right patient.

According to the policy, Multiple-dose/Single-dose Vial, the use of a multiple-dose vial should be limited to only a single patient, whenever possible, to reduce the risk of contamination.

REFERENCE

According to Micromedex, for short-term pain, the Ketorolac IV dosage recommendation for patients younger than 65 years of age is 30 mg IV as a single dose or 30 mg IV every 6 hours.

1. Nursing staff did not administer physician ordered medications to Patient #12.

a) Review of Patient #12's medical record revealed the patient presented to the Pediatric Emergency Department (ED) on 08/01/16 via ambulance after ingesting another family member's medication. Patient #12 was 13 months old. According to the physician's notes documented at 4:35 p.m., the patient had a fever upon arrival to the Pediatric ED. At 5:07 p.m., a RN assessment was conducted by RN #10. Patient #12's documented temperature was 103.7 Fahrenheit. At 5:15 p.m., the patient's documented temperature was 100.2; then at 6:10 p.m., his/her temperature was documented as 101.4.

At 4:47 p.m., Patient #12's physician ordered acetaminophen, a medication used to reduce fever, to be given to the patient. Additionally, the physician ordered for nursing staff to administer 500 milliliters of Normal Saline 0.9% intravenous (IV) fluids through Patient #12's IV catheter. There was no evidence in Patient #12's medical record showing both medications were administered as ordered. Patient #12 remained febrile upon transfer to another facility.

b) On 09/14/16 at 11:52 a.m., an interview was conducted with RN #6 who stated if a medication was ordered, then nursing staff were expected to document the administration. RN #6 stated if the parent of the child refused the medication, s/he would notify the physician and document the refusal.

Patient #12's medical record lacked any evidence the patient's parents refused the physician ordered medication.

c) On 09/14/16 at 3:09 p.m., an interview was conducted with the Director of Pediatrics (Director #5). Director #5 reviewed Patient #12's medical record and confirmed there was no evidence showing the normal saline IV fluids and the acetaminophen were administered to the febrile patient. S/he stated the nurse should have administered the medication since there was concern about the patient's fever.

2. Nursing staff failed to clarify a medication dose which exceeded the recommended dosage.

a) Review of Patient #10's medical record revealed the patient presented to the Pediatric ED on 08/10/16 for right flank pain. At 11:14 p.m., the physician ordered Ketorolac, a non-steroidal anti-inflammatory drug, 60 milligrams to be administered through Patient #10's intravenous (IV) catheter. According to the Medication Administration Record (MAR), RN #11 administered the IV medication to Patient #10. The MAR indicated RN #12 verified the dose given with RN #11. Patient #10 was 17 years old.

There was no evidence in Patient #10's medical record showing either RN #11 or RN #12 clarified with the physician as to why the dose ordered was beyond the recommended dosing range indicated on the Micromedex drug summary, used by the facility. Both RN's did not ensure the physician ordered dose for the new medication was an appropriate dose to be administered. This was in contrast to policy.

b) On 09/14/16 at 2:20 p.m., an interview was conducted with the Director of Pharmacy (Director #13) who provided the professional reference cited above and stated it was not recommended to give a patient 60 mg of IV Ketorolac. Director #13 stated 30 mg IV was the typical dose usually prescribed.

c) On 09/14/16 at 11:52 a.m., an interview was conducted with RN #6 who worked in the Pediatric ED. RN #6 reviewed Patient #10's medical record. RN #6 stated IV Ketorolac dose was usually 15 mg or 30 mg for the "big kids". RN #6 stated if s/he had concerns as to if a medication was appropriate for a patient, s/he would clarify the medication with a physician, then document the conversation. RN #6 stated s/he would also check with the pharmacy and question the 60 mg IV Ketorolac dose ordered.

d) On 09/14/16 at 3:09 p.m., an interview was conducted with Director #5 who reviewed Patient #10's medical record. Director #5 stated normally 60 mg of Ketorolac would be administered via intramuscularly. Director #5 stated s/he would have questioned the dose ordered. Director #5 stated 2 nurses were required to verify the dose ordered to ensure the dose was correct. Director #5 confirmed there was no evidence in Patient #10's medical record showing nursing staff followed the process. Director #5 stated the risk of administering a wrong dose would depend on the medication. Director #5 stated some medications could affect a patient's kidneys.

3. The facility failed to ensure multiple-dose medication vials brought into patient rooms, including isolation rooms, were dedicated for single patient use or discarded after use.

a) On 09/12/16 at 12:22 p.m., a medication administration observation was conducted on the 6th floor Medical Surgical Oncology Unit. RN #7 removed a multiple-dose insulin vial from the unit's automated dispensing machine (ADC), then proceeded to enter Patient A's room. RN #7 administered the prescribed dose of insulin via subcutaneous route into Patient A's abdomen. Upon exiting the patient's room, RN #7 placed the multiple-dose vial of insulin into his/her scrub pocket, then proceeded to return the medication vial to the unit's ADC. RN #7 did not disinfect the vial after s/he exited the patient's room and prior to placing the vial in the ADC.

During the observation, the Director (Director #8) of the unit stated the multiple-dose insulin vials were used for multiple patients on the floor.

b) On 09/14/16 at 2:00 p.m., an interview was conducted with RN #9 who stated the insulin multiple-dose medication vials were shared between patients and the vials were stored in the ADC. RN #9 stated patient medications should not be stored in scrub pockets. RN #9 stated multiple-dose insulin vials were brought into isolation patient rooms as well.

c) On 09/14/16 at 2:10 p.m., an interview was conducted with Director #8 who stated the current practice was for staff to scan the insulin multiple-dose vials in the patients' room, including isolation rooms. Director #8 stated there was a potential risk of contamination of the vial and the facility was working on changing the current process.

Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.55, EMERGENCY SERVICES was out of compliance.

A-1103 - Standard: If emergency services are provided at the hospital, the services must be integrated with other departments of the hospital. The facility failed to have a standard process to ensure pediatric patients who presented to the adult Emergency Department (ED) for emergency services were triaged and determined to be stable prior to transferring them to the pediatric ED, which was on the other side of the hospital. Specifically, the adult emergency department failed to triage and prioritize pediatric patients in 8 of 8 pediatric records reviewed for pediatric patients who presented to the adult ED (Patients #1, #6, #7, #8, #9, #10, #11, and #23). This failure created a potential for a delay in needed patient emergency care, tests, interventions, or services.

Based on interviews and document review, the facility failed to have a standard process to ensure pediatric patients who presented to the adult Emergency Department (ED) for emergency services were triaged and determined to be stable prior to transferring them to the pediatric ED, which was on the other side of the hospital. Specifically, the adult emergency department failed to triage and prioritize pediatric patients in 8 of 8 pediatric records reviewed for pediatric patients who presented to the adult ED (Patients #1, #6, #7, #8, #9, #10, #11, and #23).

This failure created a potential for a delay in needed patient emergency care, tests, interventions, or services.

FINDINGS:

POLICY

According to the policy, Emergency Department Assessment/Reassessment, patients arriving via the walk in entrance will be triaged and assessed. Registered Nurses (RNs) complete all patient assessments. In addition, patients who present urgently will be triaged and care will be prioritized based on presentation, chief complaint and triage category. Any walk in patient classified as emergent and/or resuscitative will be taken to the ED for exam room placement and treatment. Findings from the assessment will be documented on the ED nursing record.

Pediatric Critical Findings are a child with:

-Room air pulse oximetry < 90%
-Symptoms of respiratory distress (tachypnea, bradypnea, apnea, retractions, grunting, audible wheeze, stridor, nasal flaring, head bobbing, sitting in tripod position, cyanotic)
-Symptoms of shock (tachycardia, bradycardia, pale, cyanotic, decreased level of consciousness, weak pulses, capillary refill >2 seconds, cool extremities, hypotension, distant heart sounds)
-Altered mental status (inconsolable, agitated, combative, lethargic, unresponsive, disoriented, seizure)

1. The facility failed to ensure pediatric patients who presented to the adult ED were triaged, assessed and determined stable by a RN prior to being transported to the pediatric ED which was located in another area of the hospital.

a) Review of the Patient Through Put Flow Chart, for pediatric patients who arrived to the adult ED, revealed the patient was to receive a "triage and assessment" by an adult ED Registered Nurse (RN) or Emergency Medical Technician (EMT). Based on the assessment, the adult ED Physician or Physician's Assistant (PA) would perform a medical screening exam (MSE) if the pediatric patient was unstable. If the patient was "stable to transfer" they would be transferred to the pediatric ED.

b) On 09/08/16 beginning at 1:15 p.m., a tour of the adult ED and the pediatric ED was conducted with the Director of the Adult ED (Director #1) and the Director of Regulatory (Director #2). Director #1 stated the distance from the adult ED to the pediatric ED was approximately 0.22 miles. During the tour, the walk from the adult ED to the pediatric ED required the use of an elevator from the first floor to the ground floor. Director #1 stated patients could be escorted through the garden if the weather was nice.

During the tour, an interview was conducted with Emergency Medical Technician (EMT) #3 who stated when pediatric patients presented to the adult ED, s/he would complete the Pediatric Quick Screen assessment form and have a RN review the document once it was completed. Neither the EMT or the RN would sign the assessment tool identifying who completed the assessment. EMT #3 stated if the pediatric patients were non-emergent, the pediatric patient would be escorted with a RN to the pediatric ED.

Review of the Pediatric Quick Screen assessment tool revealed the form was to used to rapidly screen pediatric patients for stability prior to transition to the pediatric ED. According to the quick screen tool the RN should complete the Pediatric Assessment Triangle, which required assessment of the patient's circulation to skin, work of breathing, and general appearance.

If the pediatric patient's assessment indicated their skin was warm, pink, and dry; their breathing was even, unlabored, and no accessory muscles were used; and their general appearance was alert, active, and appropriately interacting with their parent/guardian, it was okay to move the patient to the pediatric ED as stable.

If the pediatric patient's assessment indicated their skin was pale, cool, clammy; their work of breathing was stridor, grunting, with nasal flaring and use of their accessory muscles; and their general appearance was limp, lethargic, with minimal responsiveness, the patient should be seen in the adult ED.

Review of the Pediatric Quick Screen forms, dated from 05/01/16 through 09/12/16 showed numerous forms had no patient assessments documented to determine if the pediatric patient was stable, including the required vital signs. Furthermore, there was no evidence a RN reviewed the forms, evaluated the patients, and determined the pediatric patients were stable to be transferred to the pediatric ED. This was in contrast to policy.

c) Review of Patient #1's Pediatric Quick Screen, dated incorrectly as 08/16/16, showed the patient was brought in to the Adult ED for "post-op diaphoretic". There was no documentation an Adult ED RN assessed the pediatric patient to determine if s/he was stable for transfer to the pediatric ED. The Pediatric Assessment Triangle was not completed. Additionally, there was no documentation Patient #1's respiratory rate was assessed upon arrival.

Patient #1's medical record showed the patient presented to the pediatric ED on 08/15/16 at 10:13 a.m. and was triaged at 10:15 a.m. RN #10 documented the parent of the child (POC) felt uncomfortable taking the patient home after being discharged a short time earlier from another facility after surgery. The POC noticed as s/he placed the patient in his/her car that the child was unresponsive and diaphoretic and decided not to take the patient home. According to the RN's assessment during the pediatric ED triage, the patient was responsive only to pain, diaphoretic and pale. The patient was four years old.

At 10:45 a.m., RN #6 documented an emergency note stating upon arrival to the pediatric ED, the patient was pale, pupils noted to be pin point, heart rate was 80, minimal response, and unable to answer any questions. RN #6 documented the patient was brought over from the adult ED; however, s/he did not document the time the patient presented to the adult ED. According to the medication administration record, at 10:25 a.m., Patient #1 was administered intravenous Narcan, a drug to treat narcotic overdose in an emergency situation.

There was no documentation to show when the pediatric patient arrived at the facility's adult ED and that s/he was assessed and stable to transfer to the pediatric ED located in a different area of the hospital.

d) Review of the Pediatric Quick Screen, dated 08/22/16, for Patient #6, completed by the adult ED, showed the pediatric patient presented with a chief complaint of syncope, which was a temporary loss of consciousness. The Quick Screen showed no documentation the patient's vital signs were assessed and that the Pediatric Assessment Triangle was completed by a RN to determine if Patient #6 was stable for transfer to the pediatric ED. The only information documented on the form was the patient's name, date of birth, and chief complaint.

Patient #6's medical record showed the pediatric patient was admitted on 08/22/16 to the pediatric ED at 11:42 p.m. for syncope. There was no evidence in the medical record showing the time the pediatric patient presented to the adult ED for emergency care and that s/he was assessed and triaged by nursing staff prior to being transferred to the pediatric ED.

On 09/12/16 at 3:21 p.m., an interview was conducted with Director #1 who reviewed Patient #6's medical record and the Pediatric Quick Screen. Director #1 stated there was no way to know whether an EMT or RN completed the form. Director #1 further stated there was no way to know what time the patient initially presented to the adult ED for emergency care and that the patient was assessed prior to transfer by reviewing the form.

Similar findings were found for Patients #7, #8, #9, #10, #11, and #23 in which pediatric patients presented to the adult ED for evaluation of an emergent condition and either the Pediatric Assessment Triangle was not completed by a RN to determine if the patient was stable to transfer to the pediatric ED, vital signs were not assessed, or both.

Additionally, the Pediatric Quick Screens did not identify what individual assessed the patient and determined s/he was stable for transfer and did not require immediate treatment in the adult ED.

e) On 09/13/16 at 9:10 a.m., an interview was conducted with EMT #4 who stated s/he did not enter the pediatric patient in the computer system when the patient first presented to the adult ED. EMT #4 stated s/he would fill out the pediatric assessment form, obtain the patient's vital signs, and fill out the assessment triangle. EMT #4 stated the RN would review the form and then determine if the pediatric patient would stay at the adult ED or transfer to the pediatric ED. EMT #4 stated the purpose of the quick evaluation was to determine if the patient should stay or was stable to go to the pediatric ED. S/he stated there was not a way to confirm the RN assessed the patient by looking at the form.

f) On 09/14/16 at 9:34 a.m., an interview was conducted with Director #1 who stated the Pediatric Quick screen forms were collected and given to Director #5.

On 09/14/16 at 3:09 p.m., an interview was conducted with Director #5 who stated s/he reviewed the Pediatric Quick Screen form to track the percentage of pediatric patients who presented to the adult ED. Director #5 stated s/he was the one who documented the dates on the form and there was no current monitoring process ensuring the forms were completed when pediatric patient presented to the adult ED.

Based on observations, interviews and document review, the facility failed to ensure nursing staff administered patient medications according to physician order and per the recommended dosing guidelines. Additionally, the facility failed to ensure nursing staff safely handled multiple-dose medications to reduce the risk of infection associated with the medication administration.

This failure created a potential for negative patient outcomes related to unsafe medication administration.

FINDINGS:

POLICY

According to the policy, Pediatric Medication Administration, the Registered Nurse (RN) reviews each new medication order entered by the provider/pharmacist for accuracy and completeness, including correct dose. The right medication will be administered in the right dosage, at the right time by the right route to the right patient.

According to the policy, Multiple-dose/Single-dose Vial, the use of a multiple-dose vial should be limited to only a single patient, whenever possible, to reduce the risk of contamination.

REFERENCE

According to Micromedex, for short-term pain, the Ketorolac IV dosage recommendation for patients younger than 65 years of age is 30 mg IV as a single dose or 30 mg IV every 6 hours.

1. Nursing staff did not administer physician ordered medications to Patient #12.

a) Review of Patient #12's medical record revealed the patient presented to the Pediatric Emergency Department (ED) on 08/01/16 via ambulance after ingesting another family member's medication. Patient #12 was 13 months old. According to the physician's notes documented at 4:35 p.m., the patient had a fever upon arrival to the Pediatric ED. At 5:07 p.m., a RN assessment was conducted by RN #10. Patient #12's documented temperature was 103.7 Fahrenheit. At 5:15 p.m., the patient's documented temperature was 100.2; then at 6:10 p.m., his/her temperature was documented as 101.4.

At 4:47 p.m., Patient #12's physician ordered acetaminophen, a medication used to reduce fever, to be given to the patient. Additionally, the physician ordered for nursing staff to administer 500 milliliters of Normal Saline 0.9% intravenous (IV) fluids through Patient #12's IV catheter. There was no evidence in Patient #12's medical record showing both medications were administered as ordered. Patient #12 remained febrile upon transfer to another facility.

b) On 09/14/16 at 11:52 a.m., an interview was conducted with RN #6 who stated if a medication was ordered, then nursing staff were expected to document the administration. RN #6 stated if the parent of the child refused the medication, s/he would notify the physician and document the refusal.

Patient #12's medical record lacked any evidence the patient's parents refused the physician ordered medication.

c) On 09/14/16 at 3:09 p.m., an interview was conducted with the Director of Pediatrics (Director #5). Director #5 reviewed Patient #12's medical record and confirmed there was no evidence showing the normal saline IV fluids and the acetaminophen were administered to the febrile patient. S/he stated the nurse should have administered the medication since there was concern about the patient's fever.

2. Nursing staff failed to clarify a medication dose which exceeded the recommended dosage.

a) Review of Patient #10's medical record revealed the patient presented to the Pediatric ED on 08/10/16 for right flank pain. At 11:14 p.m., the physician ordered Ketorolac, a non-steroidal anti-inflammatory drug, 60 milligrams to be administered through Patient #10's intravenous (IV) catheter. According to the Medication Administration Record (MAR), RN #11 administered the IV medication to Patient #10. The MAR indicated RN #12 verified the dose given with RN #11. Patient #10 was 17 years old.

There was no evidence in Patient #10's medical record showing either RN #11 or RN #12 clarified with the physician as to why the dose ordered was beyond the recommended dosing range indicated on the Micromedex drug summary, used by the facility. Both RN's did not ensure the physician ordered dose for the new medication was an appropriate dose to be administered. This was in contrast to policy.

b) On 09/14/16 at 2:20 p.m., an interview was conducted with the Director of Pharmacy (Director #13) who provided the professional reference cited above and stated it was not recommended to give a patient 60 mg of IV Ketorolac. Director #13 stated 30 mg IV was the typical dose usually prescribed.

c) On 09/14/16 at 11:52 a.m., an interview was conducted with RN #6 who worked in the Pediatric ED. RN #6 reviewed Patient #10's medical record. RN #6 stated IV Ketorolac dose was usually 15 mg or 30 mg for the "big kids". RN #6 stated if s/he had concerns as to if a medication was appropriate for a patient, s/he would clarify the medication with a physician, then document the conversation. RN #6 stated s/he would also check with the pharmacy and question the 60 mg IV Ketorolac dose ordered.

d) On 09/14/16 at 3:09 p.m., an interview was conducted with Director #5 who reviewed Patient #10's medical record. Director #5 stated normally 60 mg of Ketorolac would be administered via intramuscularly. Director #5 stated s/he would have questioned the dose ordered. Director #5 stated 2 nurses were required to verify the dose ordered to ensure the dose was correct. Director #5 confirmed there was no evidence in Patient #10's medical record showing nursing staff followed the process. Director #5 stated the risk of administering a wrong dose would depend on the medication. Director #5 stated some medications could affect a patient's kidneys.

3. The facility failed to ensure multiple-dose medication vials brought into patient rooms, including isolation rooms, were dedicated for single patient use or discarded after use.

a) On 09/12/16 at 12:22 p.m., a medication administration observation was conducted on the 6th floor Medical Surgical Oncology Unit. RN #7 removed a multiple-dose insulin vial from the unit's automated dispensing machine (ADC), then proceeded to enter Patient A's room. RN #7 administered the prescribed dose of insulin via subcutaneous route into Patient A's abdomen. Upon exiting the patient's room, RN #7 placed the multiple-dose vial of insulin into his/her scrub pocket, then proceeded to return the medication vial to the unit's ADC. RN #7 did not disinfect the vial after s/he exited the patient's room and prior to placing the vial in the ADC.

During the observation, the Director (Director #8) of the unit stated the multiple-dose insulin vials were used for multiple patients on the floor.

b) On 09/14/16 at 2:00 p.m., an interview was conducted with RN #9 who stated the insulin multiple-dose medication vials were shared between patients and the vials were stored in the ADC. RN #9 stated patient medications should not be stored in scrub pockets. RN #9 stated multiple-dose insulin vials were brought into isolation patient rooms as well.

c) On 09/14/16 at 2:10 p.m., an interview was conducted with Director #8 who stated the current practice was for staff to scan the insulin multiple-dose vials in the patients' room, including isolation rooms. Director #8 stated there was a potential risk of contamination of the vial and the facility was working on changing the current process.

Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation §482.55, EMERGENCY SERVICES was out of compliance.

A-1103 - Standard: If emergency services are provided at the hospital, the services must be integrated with other departments of the hospital. The facility failed to have a standard process to ensure pediatric patients who presented to the adult Emergency Department (ED) for emergency services were triaged and determined to be stable prior to transferring them to the pediatric ED, which was on the other side of the hospital. Specifically, the adult emergency department failed to triage and prioritize pediatric patients in 8 of 8 pediatric records reviewed for pediatric patients who presented to the adult ED (Patients #1, #6, #7, #8, #9, #10, #11, and #23). This failure created a potential for a delay in needed patient emergency care, tests, interventions, or services.

Based on interviews and document review, the facility failed to have a standard process to ensure pediatric patients who presented to the adult Emergency Department (ED) for emergency services were triaged and determined to be stable prior to transferring them to the pediatric ED, which was on the other side of the hospital. Specifically, the adult emergency department failed to triage and prioritize pediatric patients in 8 of 8 pediatric records reviewed for pediatric patients who presented to the adult ED (Patients #1, #6, #7, #8, #9, #10, #11, and #23).

This failure created a potential for a delay in needed patient emergency care, tests, interventions, or services.

FINDINGS:

POLICY

According to the policy, Emergency Department Assessment/Reassessment, patients arriving via the walk in entrance will be triaged and assessed. Registered Nurses (RNs) complete all patient assessments. In addition, patients who present urgently will be triaged and care will be prioritized based on presentation, chief complaint and triage category. Any walk in patient classified as emergent and/or resuscitative will be taken to the ED for exam room placement and treatment. Findings from the assessment will be documented on the ED nursing record.

Pediatric Critical Findings are a child with:

-Room air pulse oximetry < 90%
-Symptoms of respiratory distress (tachypnea, bradypnea, apnea, retractions, grunting, audible wheeze, stridor, nasal flaring, head bobbing, sitting in tripod position, cyanotic)
-Symptoms of shock (tachycardia, bradycardia, pale, cyanotic, decreased level of consciousness, weak pulses, capillary refill >2 seconds, cool extremities, hypotension, distant heart sounds)
-Altered mental status (inconsolable, agitated, combative, lethargic, unresponsive, disoriented, seizure)

1. The facility failed to ensure pediatric patients who presented to the adult ED were triaged, assessed and determined stable by a RN prior to being transported to the pediatric ED which was located in another area of the hospital.

a) Review of the Patient Through Put Flow Chart, for pediatric patients who arrived to the adult ED, revealed the patient was to receive a "triage and assessment" by an adult ED Registered Nurse (RN) or Emergency Medical Technician (EMT). Based on the assessment, the adult ED Physician or Physician's Assistant (PA) would perform a medical screening exam (MSE) if the pediatric patient was unstable. If the patient was "stable to transfer" they would be transferred to the pediatric ED.

b) On 09/08/16 beginning at 1:15 p.m., a tour of the adult ED and the pediatric ED was conducted with the Director of the Adult ED (Director #1) and the Director of Regulatory (Director #2). Director #1 stated the distance from the adult ED to the pediatric ED was approximately 0.22 miles. During the tour, the walk from the adult ED to the pediatric ED required the use of an elevator from the first floor to the ground floor. Director #1 stated patients could be escorted through the garden if the weather was nice.

During the tour, an interview was conducted with Emergency Medical Technician (EMT) #3 who stated when pediatric patients presented to the adult ED, s/he would complete the Pediatric Quick Screen assessment form and have a RN review the document once it was completed. Neither the EMT or the RN would sign the assessment tool identifying who completed the assessment. EMT #3 stated if the pediatric patients were non-emergent, the pediatric patient would be escorted with a RN to the pediatric ED.

Review of the Pediatric Quick Screen assessment tool revealed the form was to used to rapidly screen pediatric patients for stability prior to transition to the pediatric ED. According to the quick screen tool the RN should complete the Pediatric Assessment Triangle, which required assessment of the patient's circulation to skin, work of breathing, and general appearance.

If the pediatric patient's assessment indicated their skin was warm, pink, and dry; their breathing was even, unlabored, and no accessory muscles were used; and their general appearance was alert, active, and appropriately interacting with their parent/guardian, it was okay to move the patient to the pediatric ED as stable.

If the pediatric patient's assessment indicated their skin was pale, cool, clammy; their work of breathing was stridor, grunting, with nasal flaring and use of their accessory muscles; and their general appearance was limp, lethargic, with minimal responsiveness, the patient should be seen in the adult ED.

Review of the Pediatric Quick Screen forms, dated from 05/01/16 through 09/12/16 showed numerous forms had no patient assessments documented to determine if the pediatric patient was stable, including the required vital signs. Furthermore, there was no evidence a RN reviewed the forms, evaluated the patients, and determined the pediatric patients were stable to be transferred to the pediatric ED. This was in contrast to policy.

c) Review of Patient #1's Pediatric Quick Screen, dated incorrectly as 08/16/16, showed the patient was brought in to the Adult ED for "post-op diaphoretic". There was no documentation an Adult ED RN assessed the pediatric patient to determine if s/he was stable for transfer to the pediatric ED. The Pediatric Assessment Triangle was not completed. Additionally, there was no documentation Patient #1's respiratory rate was assessed upon arrival.

Patient #1's medical record showed the patient presented to the pediatric ED on 08/15/16 at 10:13 a.m. and was triaged at 10:15 a.m. RN #10 documented the parent of the child (POC) felt uncomfortable taking the patient home after being discharged a short time earlier from another facility after surgery. The POC noticed as s/he placed the patient in his/her car that the child was unresponsive and diaphoretic and decided not to take the patient home. According to the RN's assessment during the pediatric ED triage, the patient was responsive only to pain, diaphoretic and pale. The patient was four years old.

At 10:45 a.m., RN #6 documented an emergency note stating upon arrival to the pediatric ED, the patient was pale, pupils noted to be pin point, heart rate was 80, minimal response, and unable to answer any questions. RN #6 documented the patient was brought over from the adult ED; however, s/he did not document the time the patient presented to the adult ED. According to the medication administration record, at 10:25 a.m., Patient #1 was administered intravenous Narcan, a drug to treat narcotic overdose in an emergency situation.

There was no documentation to show when the pediatric patient arrived at the facility's adult ED and that s/he was assessed and stable to transfer to the pediatric ED located in a different area of the hospital.

d) Review of the Pediatric Quick Screen, dated 08/22/16, for Patient #6, completed by the adult ED, showed the pediatric patient presented with a chief complaint of syncope, which was a temporary loss of consciousness. The Quick Screen showed no documentation the patient's vital signs were assessed and that the Pediatric Assessment Triangle was completed by a RN to determine if Patient #6 was stable for transfer to the pediatric ED. The only information documented on the form was the patient's name, date of birth, and chief complaint.

Patient #6's medical record showed the pediatric patient was admitted on 08/22/16 to the pediatric ED at 11:42 p.m. for syncope. There was no evidence in the medical record showing the time the pediatric patient presented to the adult ED for emergency care and that s/he was assessed and triaged by nursing staff prior to being transferred to the pediatric ED.

On 09/12/16 at 3:21 p.m., an interview was conducted with Director #1 who reviewed Patient #6's medical record and the Pediatric Quick Screen. Director #1 stated there was no way to know whether an EMT or RN completed the form. Director #1 further stated there was no way to know what time the patient initially presented to the adult ED for emergency care and that the patient was assessed prior to transfer by reviewing the form.

Similar findings were found for Patients #7, #8, #9, #10, #11, and #23 in which pediatric patients presented to the adult ED for evaluation of an emergent condition and either the Pediatric Assessment Triangle was not completed by a RN to determine if the patient was stable to transfer to the pediatric ED, vital signs were not assessed, or both.

Additionally, the Pediatric Quick Screens did not identify what individual assessed the patient and determined s/he was stable for transfer and did not require immediate treatment in the adult ED.

e) On 09/13/16 at 9:10 a.m., an interview was conducted with EMT #4 who stated s/he did not enter the pediatric patient in the computer system when the patient first presented to the adult ED. EMT #4 stated s/he would fill out the pediatric assessment form, obtain the patient's vital signs, and fill out the assessment triangle. EMT #4 stated the RN would review the form and then determine if the pediatric patient would stay at the adult ED or transfer to the pediatric ED. EMT #4 stated the purpose of the quick evaluation was to determine if the patient should stay or was stable to go to the pediatric ED. S/he stated there was not a way to confirm the RN assessed the patient by looking at the form.

f) On 09/14/16 at 9:34 a.m., an interview was conducted with Director #1 who stated the Pediatric Quick screen forms were collected and given to Director #5.

On 09/14/16 at 3:09 p.m., an interview was conducted with Director #5 who stated s/he reviewed the Pediatric Quick Screen form to track the percentage of pediatric patients who presented to the adult ED. Director #5 stated s/he was the one who documented the dates on the form and there was no current monitoring process ensuring the forms were completed when pediatric patient presented to the adult ED.