HospitalInspections.org

The Hospital was out of compliance for the Condition of Participation for Patient Rights.

Findings included:

The Hospital failed to ensure for one (Patient #1) of 14 sampled patients that the Hospital provided care in a safe setting.

Refer to TAG: A-0144.

The Hospital failed for one (Patient #14) of 14 sampled patients to report an allegation that, on 1/10/18, Clinical Care Technician #3 inserted a finger in Patient #14's anus.

Refer to TAG: A-0145.

Based on observations, records review and interview the Hospital failed to ensure for one (Patient #1) of 14 sampled patients that the Hospital provided care in a safe setting when an emergency department patient was assaulted by staff.

Findings included:

Patient #1's emergency department record, dated 8/15/17, indicated that on this date around midnight, Patient #1 entered the Emergency Department and was evaluated for pain due to a wound received several days earlier.

The Surveyors interviewed the Director of Security and the Interim Chief Nursing Officer at 5:20 P.M. on 9/12/18. The Director of Security and the Interim Chief Nursing Officer provided a CD video recording to the Surveyors, which included a recording of hospital security staff, a Nurse (identified as Nurse #1), and an ambulance staff member interacting with Patient #1 as he/she is leaving the hospital via the ambulance bay.

The Surveyors, the Director of Security and the Interim Chief Nursing Officer viewed the video, which is time stamped starting at 1:48:46 A.M. on 8/16/17 and ending at 1:57:34 on 8/16/17.

The approximate two-minute video shows an individual (Nurse #1) walking outside of the ambulance bay crossing the street and placing Patient #1's sneakers on the sidewalk and Patient #1 following him from several feet back wearing what appears to be just socks. Patient #1 can then be seen running away from the ambulance bay, with Nurse #1 running in pursuit close behind him/her, while two Security Guards and one Boston Emergency Medical Services (EMS) employee walk from the ambulance bay towards the direction of Patient #1 and Nurse #1. Patient #1 is then seen on the video falling to the ground, rolling onto his/her back, and putting his/her hands up in a defensive motion. While Patient #1 is laying on his/her back on the ground, Nurse #1 is seen crouching over Patient #1, grabbing Patient #1's hands, and kneeling on Patient #1. Nurse #1 is seen placing his left knee on Patient #1's abdomen and his right knee on Patient #1's head and remained kneeling on Patient #1's abdomen and head as the two Security Guards and the Boston EMS employee arrive. The two Security Guards and Nurse #1 are observed to lift Patient #1 to a standing position and once Patient #1 was standing, Nurse #1 immediately lets go of Patient #1 and walked back to the ambulance bay followed by the two Security Guards.

There is no indication that Patient #1 was examined for potential injuries as a result of the fall or from Nurse #1 kneeling on his/her abdomen and head.

Patient #1's hospital records indicated that at no time was Patient #1 returned to the Emergency Department for an evaluation and there is no indication that there were attempts to arrange for an alternate hospital to evaluate Patient #1.

The video indicated that, after hospital staff walk away from Patient #1, he/she is on the sidewalk and one of the Security Guards is seen to bend over, pick up one of Patient #1's sneakers and throw it out of camera range. The video time jumps/skips for five seconds and then shows Patient #1 walking towards the ambulance bay and the same Security Guard bending down, picking up Patient #1's second sneaker and throwing it away from Patient #1 where it landed in the street.

After viewing the video, the Director of Security and the Interim Chief Nursing Officer told Surveyors they were unable to identify or provide the Surveyors with the name of Patient #1 or the Security Guards involved in the incident.

The Surveyor interviewed Patient #1 at 7:00 P.M. on 9/12/18. Patient #1 said that he/she came to the Emergency Department in the late evening of 8/15/17 around midnight. Patient #1 said that his/her chief complaint was pain from a wound received several days earlier. Patient #1 said he/she was displeased with his/her care and was told to leave by staff. Patient #1 said that Nurse #1 told him to "Get the f--- out of here", or words to that effect, and Security made him/her leave. Patient #1 said that he/she left through the ambulance bay doors but wanted to stay. Patient #1 said that Nurse #1 took his/her sneakers and put them outside which upset him/her. Patient #1 said that he/she, Nurse #1 and the two Security Guards were all yelling at each other. Patient #1 said that they wanted him/her to leave and he/she wanted to stay.

Patient #1 said that he/she then walked across the street wearing only socks and picked up his/her sneakers (previously left there by Nurse #1) and threw them towards Nurse #1 and the Security Guards. Patient #1 said that Nurse #1 then chased him/her across the street and he/she fell while running from Nurse #1. Patient #1 said he/she ran because he/she thought Nurse #1 would hurt him/her. Patient #1 said that after he/she fell to the ground, Nurse #1 knelt on his/her chest and said "Don't come back.", or words to that effect. Patient #1 said they then lifted him/her up onto his/her feet and again said "Don't come back." or words to that effect. Patient #1 said that Security then threw his/her sneakers so he/she would have to walk to go get them.

Patient #1 said that no one checked him/her for injuries and that at no time did Nurse #1 or the Security Guards offer him/her to be seen in the Emergency Department, Patient #1 said that he/she was never interviewed or contacted by the Hospital about this incident.

The Surveyors interviewed Nurse #1 at 2:05 P.M. on 9/13/18. Nurse #1 said that, during his shift on 8/16/17, he was assigned to care for Patient #1. Nurse #1 said that Patient #1 was discharged and would not leave or put on his/her sneakers. Nurse #1 said that he could not recall why Patient #1 refused to leave. Nurse #1 said that eventually Patient #1 left the Emergency Department but left his/her belongings inside. Nurse #1 said he took Patient #1's belongings and left the Emergency Department to give them to Patient #1. Nurse #1 said that he put his sneakers next to Patient #1 at the ambulance bay. Nurse #1 said that at that time Patient #1 threw his/her sneakers at Nurse#1. Nurse #1 said that Patient #1 then walked into the street and Nurse #1 walked towards him/her because Nurse #1 was concerned that Patient #1 was in the street. Nurse #1 said that Patient #1 then turned and fell and he ran over to him/her to make sure he/she was okay. Nurse #1 said that he asked Patient #1 if he/she was okay and wanted to be seen in the Emergency Department (ED) and at that point Patient #1 said that he/she had a knife. Nurse #1 said that he then left Patient #1 and went back into the ED.

Nurse #1's account of the interaction is not consistent with Patient #1's account and is not consistent with the video recording of the incident.

Nurse #1 said that he did not call a safety code (Code Purple), alert his co-workers or call the police. Nurse #1 said he went back to work. Nurse #1 said that the next evening he wrote an incident report. Nurse #1 said that as a result of this incident he was spoken to by his manager and went to three or four meetings with the Employee Assistance Program. Nurse #1 said he was never placed on leave of duty.

Based on observations, records review and interview the Hospital failed to ensure for two (Patient #1 & Patient #14) out of 14 sampled patients that care was free from all forms of abuse and harassment.

- Patient #1, the Hospital failed to provide care free from all forms of abuse and harassment when an emergency department patient had his/her shoes placed outside the Hospital on the sidewalk requiring Patient #1 to leave the hospital in stocking feet to retrieve the shoes; had his/her shoes thrown in his/her direction by a Security Staff member; and, when he/she was then assaulted by a staff member, later identified as Nurse #1.

- The Hospital failed to complete a thorough investigation of the incident involving Patient #1 and interactions with three Hospital staff and an ambulance company staff member.

- Patient #14, the Hospital failed to complete a thorough investigation and appropriately report an allegation that a staff member inserted his finger into Patient #14's anus.

Findings included:

Patient #1's emergency department record, dated 8/15/17, indicated that on this date around midnight, Patient #1 entered the Emergency Department and was evaluated for pain due to a wound received several days earlier.

An electronic mail document, dated 8/17/17, indicated the Clinical Nurse Director of Emergency Services forwarded an email to the Director of Employee Relations at 7:09 A.M. on 8/17/17. Included with the email was an attachment that was sent to her at 11:48 P.M. on 8/16/17 from Nurse #1. The email indicated that Nurse #1 provided the Clinical Nurse Director of the Emergency Department information in the email regarding an interaction between Nurse #1 and Patient #1 where Nurse #1 indicated that Patient #1 started to run away from him and fell to the ground. Nurse #1 indicated that he did not want to leave him/her lying in the street so he continued to run to him/her. Nurse #1 indicated that Patient #1 muttered about having a knife so he restrained Patient #1's arms. Nurse #1 indicated that two Security Guards were there to assist Nurse #1 and the three individuals helped Patient #1 to stand up. Nurse #1 indicated that Patient #1 refused to come back inside for an exam.

The Surveyors interviewed the Director of Security and the Interim Chief Nursing Officer at 5:20 P.M. on 9/12/18. The Director of Security and the Interim Chief Nursing Officer provided a CD video recording to the Surveyors, which included a recording of hospital Security Staff, a Nurse (identified as Nurse #1), and an ambulance staff member interacting with Patient #1 as he/she is leaving the hospital via the ambulance bay.

The Surveyors, the Director of Security and the Interim Chief Nursing Officer viewed the video, which is time stamped starting at 1:48:46 A.M. on 8/16/17 and ending at 1:57:34 on 8/16/17.

The approximate two-minute video shows an individual (Nurse #1) walking outside of the ambulance bay crossing the street and placing Patient #1's sneakers on the sidewalk and Patient #1 following him from several feet back wearing what appears to be just socks. Patient #1 can then be seen running away from the ambulance bay, with Nurse #1 running in pursuit close behind him/her, while two Security Guards and one Boston Emergency Medical Services (EMS) employee walk from the ambulance bay towards the direction of Patient #1 and Nurse #1. Patient #1 is then seen on the video falling to the ground, rolling onto his/her back, and putting his/her hands up in a defensive motion. While Patient #1 is laying on his/her back on the ground, Nurse #1 is seen crouching over Patient #1, grabbing Patient #1's hands, and kneeling on Patient #1. Nurse #1 is seen placing his left knee on Patient #1's abdomen and his right knee on Patient #1's head and remained kneeling on Patient #1's abdomen and head as the two Security Guards and the Boston EMS employee arrive. The two Security Guards and Nurse #1 are observed to lift Patient #1 to a standing position and, once Patient #1 was standing, Nurse #1 immediately lets go of Patient #1 and walks back to the ambulance bay followed by the two Security Guards.

There is no indication that Patient #1 was examined for potential injuries as a result of the fall or from Nurse #1 kneeling on his/her abdomen and head.

Patient #1's hospital records did not indicate that Patient #1 returned to the Emergency Department for an evaluation and there is no indication that there were attempts to arrange for an alternate hospital to evaluate Patient #1.

The video indicated that after hospital staff walk away from Patient #1, he/she is on the sidewalk and one of the Security Guards is seen to bend over, pick up one of Patient #1's sneakers, and throw it out of camera range. The video time jumps/skips for five seconds and the shows Patient #1 walking towards the ambulance bay and the same Security Guard bending down, picking up Patient #1's second sneaker and throwing it away from Patient #1 where it landed in the street.

After viewing the video, the Director of Security and the Interim Chief Nursing Officer told Surveyors they were unable to identify or provide the Surveyors with the name of Patient #1 or the Security Guards involved in the incident.

The Surveyor interviewed Patient #1 at 7:00 P.M. on 9/12/18. Patient #1 said that he/she came to the Emergency Department in the late evening of 8/15/17 around midnight. Patient #1 said that his/her chief complaint was pain from a wound received several days earlier. Patient #1 said he/she was displeased with his/her care and was told to leave by staff. Patient #1 said that Nurse #1 told him to "Get the fuck out of here", or words to that effect, and Security made him/her leave. Patient #1 said that he/she left through the ambulance bay doors but wanted to stay. Patient #1 said that Nurse #1 took his/her sneakers and put them outside which upset him/her. Patient #1 said that he/she, Nurse #1 and the two Security Guards were all yelling at each other. Patient #1 said that they wanted him/her to leave and he/she wanted to stay.

Patient #1 said that he/she then walked across the street wearing only socks and picked up his/her sneakers (previously left there by Nurse #1) and threw them towards Nurse #1 and the Security Guards. Patient #1 said that Nurse #1 then chased him/her across the street and he/she fell while running from Nurse #1. Patient #1 said he/she ran because he/she thought Nurse #1 would hurt him/her. Patient #1 said that after he/she fell to the ground, Nurse #1 knelt on his/her chest and said "Don't come back", or words to that effect. Patient #1 said they then lifted him/her up onto his/her feet and again said "Don't come back", or words to that effect. Patient #1 said that Security then threw his/her sneakers so he/she would have to walk to go get them.

Patient #1 said that no one checked him/her for injuries and at no time did Nurse #1 or the Security Guards offer him/her to be seen in the Emergency Department. Patient #1 said that he/she was never interviewed or contacted by the Hospital about this incident.

The Surveyors interviewed Nurse #1 at 2:05 P.M. on 9/13/18. Nurse #1 said that, during his shift on 8/16/17, he was assigned to care for Patient #1. Nurse #1 said that Patient #1 was discharged and would not leave or put on his/her sneakers. Nurse #1 said that he could not recall why Patient #1 refused to leave. Nurse #1 said that eventually Patient #1 left the Emergency Department but left his/her belongings inside. Nurse #1 said he took Patient #1's belongings and left the Emergency Department to give them to Patient #1. Nurse #1 said that he put his/her sneakers next to Patient # 1 at the ambulance bay. Nurse #1 said that at that time Patient #1 threw his/her sneakers at Nurse #1. Nurse #1 said that Patient #1 then walked into the street and Nurse #1 walked towards him/her because Nurse #1 was concerned that Patient #1 was in the street. Nurse #1 said that Patient #1 then turned and fell and he ran over to him/hr to make sure he/she was okay. Nurse #1 said that he asked Patient #1 if he/she was okay and wanted to be seen in the Emergency Department (ED) and at that point Patient #1 said that he/she had a knife. Nurse #1 said that he then left Patient #1 and went back into the ED.

Nurse #1's account of the interaction is not consistent with Patient #1's account and is not consistent with the video recording of the incident.

Nurse #1 said that he did not call a safety code (Code Purple), alert his co-workers, or call the police. Nurse #1 said he went back to work. Nurse #1 said that the next evening he wrote an incident report. Nurse #1 said that as a result of this incident he was spoken to by his manager and went to three or four meetings with the Employee Assistance Program. Nurse #1 said he was never placed on leave of duty.

2. For Patient #14, the Hospital failed to follow their policy and report an allegation that, on 1/10/18, Clinical Care Technician (CCT) #3 inserted a finger into Patient #14's anus.

The Hospital's Sexual Assault Clinical Practice Guideline, effective December 2015, indicated that rape is defined as the natural or unnatural intercourse by force against a person's will. The Guideline indicated that natural or unnatural intercourse includes penetration of the genital area or anus by penis, finger, tongue or object. The Guideline indicated that the physician was required to report rapes and sexual assaults to the police in the town where the rape or sexual assault occurred. The Guideline indicated that clinicians were mandated to report any suspicion of sexual abuse of the elderly or persons with disabilities per the Elder Abuses Protocols.

The Hospital's Suspected Elder Abuse/Neglect Hospital Wide Policy, effective July 2015, indicated that hospital mandated reporters who have reasonable cause to believe that a person aged 60 or over was suffering from abuse must report the allegation to the appropriate department or designated agency. The Policy indicated that if the elder was a nursing home resident the report should be filed with the Department of Public Health.

Patient #14's hospital record indicated he/she was over age 60 and resided in a nursing home.

The Safety Event Entry Form, dated 1/10/18 at 4:00 A.M., indicated Patient #14 complained to a nurse that CCT #3 stuck his finger in his/her anus. The Safety Event Entry indicated Risk Manager #1 was contacted and would follow up.

The Surveyor interviewed Risk Manager #1 at 12:00 P.M. on 9/13/18. Risk Manager #1 said that she investigated Patient #1's allegation with the Director of Employee and Labor Relations. The Risk Manager #1 interviewed CCT#3 who denied the allegation. Risk Manager #1 said that she interviewed Patient #14 and Patient #14 said that CCT #3 stuck his finger up his/her anus and he/she squeezed it out.

The Surveyor asked Risk Manager #1 whether she reported Patient #14's allegation to the Department of Public Health. Risk Manager #1 said that she did not because after the review by risk management the allegation was unsubstantiated.

The Hospital was out of compliance for the Condition of Participation for Quality Assessment & Performance Improvement (QAPI).

Findings include:

The Hospital failed to ensure for one (Patient #1) of 14 sampled patients that QAPI activities completed a comprehensive review of an incident which involved a staff member assaulting Patient #1.

Refer to TAG: A-0273.

Based on records reviewed and interviews, the Hospital failed to complete a comprehensive review of an incident which involved a staff member assaulting a patient. On 8/16/17, an emergency department patient had his/her shoes placed outside the Hospital on the sidewalk by a staff member requiring Patient #1 to leave the Hospital in stocking feet to retrieve the shoes; had his/her shoes thrown in his/her direction by a security staff member; and he/she was assaulted by a staff member, later identified as Nurse #1.

- The Hospital failed to complete a thorough investigation of the incident involving Patient #1 and interactions with three Hospital staff and an ambulance company staff member.

- Although Nurse #1 provided information to a Hospital staff member regarding his interactions with Patient #1 on 8/16/17, his account of the interaction was not consistent with video recording, which were readily available for review. There is not indication that Hospital leadership responded to the inconsistencies or took thorough corrective action in response to Nurse #1's assault/physical altercation with Patient #1.

- Although the video indicated Nurse #1, two security staff members, and one ambulance company staff member were involved, the Hospital staff did not provide any information to Surveyors to indicate that the Security or ambulance staff were interviewed as part of the investigation; Hospital staff informed Surveyors that they did not know the identities of the staff members (except Nurse #1) seen on the video. There is no indication the Hospital took any corrective action with a Security Staff member seen throwing Patient #1's shoes into the street.

- The incident was not reported to the Department of Public Health and was not investigated by the Hospital's Quality Department or Risk Management as required by the Hospital's policies and procedures.

Findings included:

An electronic mail document, dated 8/17/17, indicated the Clinical Nurse Director of Emergency Services forwarded an email to the Director of Employee Relations at 7:09 A.M. on 8/17/17, which indicated she that she was worried about Nurse #1 and his treatment of patients. Included with the email was an attached an email that was sent to her at 11:48 P.M. on 8/16/17 from Nurse #1. The email indicated that there was an interaction between Nurse #1 and Patient #1 where Nurse #1 indicated that Patient #1 started to run away from him and fell to the ground. Nurse #1 indicated that he did not want to leave him/her lying in the street so he continued to run to him/her. Nurse #1 indicated that Patient #1 muttered about having a knife so he restrained Patient #1's arms. Nurse #1 indicated that two Security Guards were there to assist Nurse #1 and the three individuals helped Patient #1 to stand up. Nurse #1 indicated that Patient #1 refused to come back inside for an exam. The email account is not consistent with the information contained in the video.

The Surveyors interviewed the Director of Security and the Interim Chief Nursing Officer at 5:20 P.M. on 9/12/18. The Surveyors, the Director of Security and the Interim Chief Nursing Officer viewed the video which is time stamped starting at 1:48:46 A.M. on 8/16/17 and ending at 1:57:34 on 8/16/17. The video shows interactions with Patient #1, two security staff, and one ambulance staff member. The video shows where an emergency department patient (Patient #1) had his/her shoes placed outside the hospital on the sidewalk by a staff member requiring Patient #1 to leave the hospital in stocking feet to retrieve the shoes; had his/her shoes thrown in his/her direction by a security staff member; and he/she was assaulted by a staff member, later identified as Nurse #1.

The altercation seen on video shows Nurse #1 running toward Patient #1, Patient #1 falling as he/she is seen trying to run away from Nurse #1 in stocking feet. Nurse #1 is seen kneeling on Patient #1's abdomen and head until Patient #1 is assisted to a standing position by all staff involved.

The Surveyors interviewed the Clinical Nurse Director of Emergency Services at 1:53 P.M. on 9/12/18. The Clinical Nurse Director of Emergency Services said that Nurse #1 was disciplined for an altercation with an Emergency Department patient (later identified as Patient #1) in August, 2017. The Clinical Nurse Director of Emergency Services said that Nurse #1 was involved in what was described to Surveyors as a verbal altercation with Patient #1 during his/her discharge. The Clinical Nurse Director of Emergency Services said that the incident was on video and that Patient #1 threw his/her sneaker at Nurse #1 and struck him in the leg and Nurse #1 responded by lunging at Patient #1 and Patient #1 fell to the ground. The Clinical Nurse Director of Emergency Services said that Patient #1 was not injured and refused further medical treatment. The account of the Clinical Nurse Director of the Emergency Department is not consistent with the information obtained from the video.

The Clinical Nurse Director of Emergency Services said that Nurse #1 filed an internal incident report. The Clinical Nurse Director of Emergency Services said she was not involved in the Hospital's investigation and that it was conducted by the Director of Employee Relations. The Clinical Nurse Director of Emergency Services said that Nurse #1 was not reported to the Board of Registration in Nursing, but did receive a written warning regarding the altercation. The Clinical Nurse Director of Emergency Services said that she didn't recall if Nurse #1 was suspended or disciplined other than receiving a written warning. The Clinical Nurse Director of Emergency Services said that Nurse #1 told her that he was frustrated and burnt out. The Clinical Nurse Director of Emergency Services said that he was referred to the Employee Assistance Program for his anger and frustration issues. The Clinical Nurse Director of Emergency Services said that Nurse #1 was placed on the day shift for a few weeks as a means to decrease his stress.

The Document titled, [Hospital Name Removed] Medical Center: Documentation of Action for Registered Nurses, dated 9/21/17, indicated that Nurse #1 sent the Clinical Nurse Director of Emergency Services an email later that shift and said that he was feeling very burnt out, tired of being yelled at, spit at, and hit at work. Nurse #1 states that he did not like who he had become and was less compassionate and extremely frustrated.

The Surveyors interviewed the Director of Employee Relations at 3:50 P.M. on 9/12/18, The Director of Employee Relations said that she could not find the investigation conducted about the employee assault and that it may take one or two days to find.

The Director of Employee Relations initially told Surveyors that she could not recall the Patient's name or the date the incident occurred. In a subsequent interview on 9/13/18, the Director of Employee Relations provided more information.

The Hospital was unable to provide any information to indicate that a comprehensive investigation was completed, which would include interviews from all staff involved.

The Hospital was unable to provide any information to indicate that corrective action plans for all staff were developed or monitored in response to the incident in an effort to ensure patients were not harassed, abused, or assaulted by staff.

Nurse #1 continued to work in the emergency department. The Hospital was unable to provide any detailed information to indicate that Nurse #1's interactions with patients was being monitored.

In a subsequent interview at 12:30 P.M. on 9/13/18, the Director of Employee Relations said that she performed the investigation of the 8/17/17 incident involving Patient #1 and Nurse #1. The Director of Employee Relations said that she was notified of the incident by the Clinical Nurse Director of Emergency Services within a day or two of the incident. The Director of Employee Relations said that she interviewed the Clinical Director of Emergency Services and read the statement made by Nurse #1 and the internal report that Nurse #1 filed the next day after the incident. The Director of Employee Relations said that she then interviewed Nurse #1. The Director of Employee Relations said that there were inconsistencies with Nurse #1's report but due to his ability to perform in the Emergency Department it was decided that his corrective actions would be a written warning and referral to the Employee Assistance Program.

There is no indication that the Director of Employee Services addressed or responded to Nurse #1's inaccurate and inconsistent account of the incident.

The Director of Employee Relations said that she did not give the report to or notify anyone else at the hospital about the investigation. There is no indication that the police were informed or that a report of the physical assault was reported to the Department of Public Health, or that a referral was made to the Board of Registration in Nursing regarding Nurse #1's interaction with Patient #1.

The Director of Employee Relations said she did not involve Risk Management or Quality and did not report her findings to senior management.

The Director of Employee Relations provided email documentation that Nurse #1 attended one meeting with a counselor from the Employee Assistance Program. The Director of Employee Relations provided a one page document from a note book that was handwritten with thirteen bullet points reviewing Nurse #1's actions.

Although the Director of Employee Relations interviewed Nurse #1 and reviewed documentation provided by Nurse #1, this did not constitute a complete and thorough investigation regarding the physical assault/abuse and harassment of Patient #1 which occurred on 8/16/17. There was no indication that the Hospital contacted or interviewed Patient #1, the two Security Guards, or the ambulance staff member about the incident.

There was no indication that follow up corrective action or discipline was provided to all staff on the video.


Refer to A 144 and A 145

Based on records reviewed and interviews the Hospital failed to follow their policies and procedures for patients being registered in their Emergency Department through the triage process.

Findings included:

Emergency service or emergency department policies must be current and revised as necessary based on the ongoing monitoring conducted by the medical staff and the emergency service or departmental Quality Assessment Performance Improvement (QAPI) activities.

The Surveyors interviewed Clinical Care Technician (CCT) #1 at 12:50 P.M. on 9/12/18. CCT #1 said that when a patient arrives and the triage staff are busy with other patients, a patient is instructed to fill out a piece of paper (blue for adult and green for pediatrics) and place it face down in a basket at the Pre-Triage area. CCT#1 said the piece of paper has the patient's name and chief complaint. CCT#1 said that when they retrieve the paper from the basket, they call the person's name and begin the pre-triage process of obtaining vital signs and registering the patient. CCT #1 said that if they pick up the paper from the basket, call the name on it and no one answers, they hold on to the paper for a little longer and try again. CCT #1 said if no one answers by the end of her shift or a couple hours, the paper is thrown away and the patient information is not registered.

The Surveyors reviewed the document titled "ED Triage Greeter Process Guideline" dated August, 2017. The document indicates that all patients who present to the emergency department requesting a medical screening examination will be logged into the Emergency Department Information System (EDIS) currently in use. The pre-triage greeter is the primary individual responsible for logging a patient into the system. Alternatively, nursing staff may perform this function or a designated individual identified by the Emergency Department Charge Nurse may perform this function. The disposition of each patient in the log will be noted by appropriate staff in compliance with all regulatory bodies. The policy does not mention the envelope at the front desk, who is responsible for it, or what the process is for placing patient information in the envelope.

The Surveyors interviewed CCT #2 at 9:06 A.M. on 9/14/18. CCT #2 said that when she takes the triage paper from the basket and if no one responds, she places the paper in an envelope located at the front desk. CCT #2 said that the envelope is then given to the Charge Nurse. CCT #2 said that she did not know what the Charge Nurse did with the information or contents of the envelope.

The Surveyors interviewed Charge Nurse #1 at 9:25 A.M. on 9/14/18. Charge Nurse #1 said she did not know anything about the envelope kept at the Triage desk and told Surveyors when interviewed that this was the first she has heard about the envelope. Charge Nurse #1 said she has worked in the Emergency Department for seven years.

The Surveyors interviewed the Emergency Department Clinical Educator at 9:30 A.M. on 9/14/18. The Emergency Department Clinical Educator said that the expectation for the CCT at triage is to enter all patients into the Emergency Department computer system if they filled out a piece of paper with their information on it while in Triage. The Emergency Department Clinical Educator said even if the patient has left the building and was not seen by the Triage Nurse, the patient information is entered into the computer and they are designated as left before being seen. If the patient completes a form, leaves without being seen and the form is illegible, the form is put into an envelope at the desk. The envelope is then collected and reviewed by the Nurse Manager or the Director of Emergency Nursing. The Emergency Department Clinical Educator said that she was not sure what happened to the information in the envelope.

The Surveyors interviewed the Clinical Nurse Director of Emergency Services at 10:00 A.M. on 9/14/18. The Clinical Nurse Director of Emergency Services said that the CCT at the triage desk should put any illegible forms that are filled out at the Triage area in the envelope at the Triage desk. The Clinical Nurse Director of Emergency Services said that she was not sure who collected the envelope that was at the front desk. The Clinical Nurse Director of Emergency Services said that she did not collect the envelope.

The Surveyors interviewed the Lead CCT of the Emergency Department at 10:30 A.M. on 9/14/18. The Lead CCT said that she was now going to be in charge of collecting the envelope at the front desk and she would give it to the Emergency Department Clinical Educator. The Lead CCT of the Emergency Department said that the envelope use to be collected by an individual who worked in Risk Management but could not remember the person's name as they have not been employed for several months. The Lead CCT of the Emergency Department said that she will now start collecting the envelope from the Triage desk. The Lead CCT of the Emergency Department said she does not know who has the envelopes from the past several months and did not know what was done with the envelopes when they were collected.