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Based on record review and interview, the facility failed to ensure patients were informed of all patient rights at the time of admission including the process for addressing patient complaints concerning the quality of care in 4 of 18 sampled patients reviewed (Patient #'s 5, 9, 17, and 18). The facility failed to inform patients of the process to file a complaint including the correct complaint hotline number in the Emergency waiting areas. Also, the facility failed to inform patients of the process to file a complaint/grievance, including the correct complaint hotline number, in the admission packet in 4 patients.


This deficient practice had the likelihood to cause harm to all patients admitted to the facility.


Findings include:

During a tour on 10-2-2018 after 1:30 PM the following observations were made:

The Patient rights notice was hanging on the wall next to the quick registration desk in the waiting room. The rights were in Spanish and English. The phone number on the Patient rights posting that included instructions for filing a complaint was incorrect. The phone number listed was 888-963-7111, this is an incorrect number.

The waiting room had three areas for patients to wait; Quick registration, Fast Track area, and the Triage area. The only area that had Patient Rights posted was the Quick registration area.


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Review of Patient rights information in the clinical records on Patient #'s 5, 9, 17 and 18 revealed the incorrect complaint number for the State regulatory agency was given to the patients.

During an interview on 10/02/2018 after 2:30 p.m., Staff #4 confirmed the incorrect number was also on the patient's information that was being given out.

Based on interview and record review, the facility failed to ensure a prompt resolution to patient's grievances. The facility failed to perform a thorough investigation so grievances could be resolved on 2 of 18 sampled patients (Patient #'s 17 and 18).

The facility failed to ensure staff involved in grievances concerning care in the Emergency department (ED) were interviewed and documentation of interviews were included in their investigations before being finalized.

This deficient practice had the likelihood to cause harm to all patients.



Findings include:

Review of the facility's complaint and grievances revealed the following:



Patient #17

On 09/10/2018 Patient #17 alleged he had heart issues and was not seen in a timely manner in the Emergency department (ED) on 06/14/2018.

Review of the facility's investigation revealed no documentation of statements being taken from the registration clerk, nurse involved and the nurse practitioner who was on duty in the ED on the date in question.

The initial letter to Patient #17 acknowledging his complaint was dated 09/10/2018.

During an interview on 10/03/2018 after 10:00 a.m., Staff #17 reported that when Patient #17 came in the ED on 06/14/2018, he was yelling that he needed help. He complained of having shortness of breath and his arm was tingling. Staff #17 reported that she and the nurse practitioner was with a patient in triage. Patient #17 came up and started beating on the triage window. The nurse practitioner stepped out and told him to go register first. Patient #17 got mad and left out of the ED. When the patient was brought back into the ED by administration he jerked the sign off the window which talked about the chest pain protocol. Staff #17 reported she could not remember if a registration clerk was up front.

During an interview on 10/03/2018 after 3:20 p.m., Staff #14 reported that when she gets the complaints, the information is sent to the director over the department involved. One also is sent to the quality department.

Staff #14 revealed the investigation was final and they had come to a conclusion and had provided a final letter dated 09/26/2018.


During an interview on 10/03/2018 after 3:20 p.m., Staff #4 (Director of Quality) reported not knowing how to access the computerized complaint system which had all of the complaint information. Staff #4 reported that she had not completed her interview with the triage nurse as of 10/03/2018.

A decision had been determined about the allegation without all the staff involved being interviewed.




Patient #18


Review of another investigation revealed Patient #18 called in a complaint on 07/30/2018 about his care in the ED on 07/24/2018. Some of the things Patient #18 complained about was lab test, staff being unable to access information, and being put back into the waiting room. On 07/31/2018, Staff #3 (Interim Chief nursing officer) called Patient #18 back and informed him the chart was under review.

On 08/03/2018 the complaint was closed out. No problems were found with the chart, but the Director over ED was counseled about fast track being used incorrectly.

Review of the investigation revealed no documentation of the staff involved being interviewed as of 10/03/2018.

During an interview on 10/03/2018 after 3:20 p.m., Staff #14 confirmed not having statements from the staff involved and that the investigation was completed on 08/03/2018.



Review of the facility's policy named "Patient Complaint & Grievance Policy Guidelines" dated 05/14/2018 revealed the following:

"..The following steps will be taken to address a complaint:

1. Interview complainant

2. Take appropriate steps to resolve the problem

3. Provide feedback to patient regarding steps taken and anticipated resolution

4. Document complaint and actions taken to resolve the issue

5. A complaint received by Administration or sources other than the department itself, shall be route immediately to the appropriate department manager for timely resolution and response.."

Based on observation, interview, and record review, the facility failed to ensure orders for blood transfusions were complete and followed before administration in 5 of 5 patients reviewed (Patient #'s 1, 2, 10, 13, and 14). The facility failed to ensure that there was a physician order to administer blood in 1 patient reviewed. The facility failed to ensure there was rate and time frame specified in physician orders for 5 patients reviewed. Also, the facility failed to ensure that the facility policy addressed all components required by the physician when writing orders for blood administration.


This deficient practice had the likelihood to cause harm in all patients who received blood transfusions.


Findings include:

PATIENT #1

Review of the History and Physical revealed a 22-year-old Hispanic male with a past medical history of significant for focal glomerulosclerosis as a child. The Plan for Patient #1 states, "the patient will be typed and crossed and transfused packed red blood cell."

Review of the Physician orders on 3-12-18 revealed an order that stated, "Red blood cells: 2 units, Indication Hgb (Hemoglobin) less than 8 or HCT (Hematocrit) less than 24. Transfuse over 4 hours." There was no rate specified.

Review of the Blood transfusion record on 3-12-2018 revealed the following:

RBC (Red Blood Cell) unit was started at 1144 PM. The transfusion was completed on 3-13-2018 at 1:45 AM. The unit was infused in 2 hours, 2 hours faster than the order stated.


Review of the Blood transfusion record on 3-13-2018 revealed the following:

RBC unit was started on 3-13-2018 at 805 AM. The unit was completed at 1210 PM.


Review of the Physician orders on 3-14-2018 revealed an order that stated. "RBC Crossmatch 2." There was no order to transfuse.


Review of the Blood transfusion record on 3-14-2018 revealed the following:

RBC Unit was started on 3-14-2018 at 0845 AM. The blood was completed at 0915 AM, 30 minutes after starting the unit. There was no physician order to administer the unit of blood.

RBC unit was started on 3-14-2018 at 1000 AM. The blood was completed at 1030, 30 minutes after the starting the unit. There was no order to administer the unit of blood.


PATIENT #2

The History and Physical revealed an 83 year old male with a history of dementia from the nursing home. The patient was sent from the nursing home with abnormal lab results. The assessment and plan for Patient #2 states, " ...Anemia, recheck labs tomorrow"

Review of the Physician orders on 3-14-2018 revealed an order that stated, "Transfuse 2 units of blood." There was no rate or timeframe's specified in the order.


Review of the Blood transfusion record on 3-14-2018 revealed the following:

RBC Unit was started on 3-14-2018 at 0845 AM. The blood was completed at 0915 AM, 30 minutes after starting the unit.


Review of the Blood Administration record for 3-14-2018 revealed the following:

RBC unit was started on 3-14-2018 at 2:45 PM. The unit was completed at 7:00 PM.


PATIENT #10

Review of the Physician orders on 10-1-2018 revealed an order that stated, "Administer 1 unit for HGB less than 7." There was no rate or timeframe's specified in the order.

Review of the Blood Product Transfusion record revealed the following:

Blood product started at 1:07 PM. The documentation did not indicate what blood product was given. The completion time showed 6:56 PM, almost 6 hours after blood product was started.


PATIENT #13

Review of the Physician orders on 9-29-2018 revealed an order that stated, "Administer 1 unit." There was no rate or timeframe specified in the order.

Review of the Blood transfusion record revealed the following:

PRBC (Packed Red Blood Cell) unit started on 9-29-2018 at 3:58 PM. The completion time could not be determined from the documentation provided by the facility.


PATIENT #14

Review of the Physician orders on 9-28-2018 revealed an order that stated, "Administer 2 units." There was no rate or timeframe specified in the order.

Review of the Blood Product Transfusion record revealed the following:

Packed Red Blood cell unit was started on 9-29-2018 at 9:22 AM. The completion time showed 12:48 PM, 3 hours later.

Packed Red Blood cell unit was started on 9-29-2018 at 2:47 PM. The completion time could not be determined from the documentation provided by the facility.


Staff #11 confirmed the above findings.


Review of the facility policy titled, "Administration: Blood and Blood Component Therapy" revealed the following:

..." Procedure:
1. All patients receiving blood components shall have a written physician's order, specifying the type of blood component to be transfused."

13. All red blood cells shall be infused within 4 hours from time of issue unless otherwise indicated."

The facility policy did not specify all components required by the physician when writing orders for blood administration.

Based on observation, interview, and record review, the facility failed to ensure adequate laboratory services to meet the needs of patients. The facility failed to:

A. ensure patients with Stat (immediate) lab orders were processed timely on 3 of 18 sampled patients (Patient #'s 9, 17, and 18). Some tests results were over an hour after being ordered. One of the patients who was waiting on test results was kept in the waiting room, putting other patients at risk for infection.

Lab turn around times for the Emergency department showed it was taking an extended time to obtain the Stat lab results.


B. ensure there were sufficient staff at all times to provide services for the entire hospital. Review of timesheets for phlebotomist from 09/09-30/2018 revealed that 1 or 2 staff were working on 7 weekend shifts during this timeframe. The hospital had 5 floor with patient care areas which depended on lab services.


Refer to A tag 0582 for additional information.

Based on observation, interview, and record review, the facility failed to:

A. ensure patients with Stat (immediate) lab orders were processed timely on 3 of 18 sampled patients (Patient #'s 9, 17, and 18). Some test results were over an hour after being ordered. One of the patients who was waiting on test results was kept in the waiting room, putting other patients at risk for infection.

Lab turn around times for the Emergency department showed it was taking an extended time to obtain the Stat lab results.


B. ensure there were sufficient staff at all times to provide services for the entire hospital. Review of timesheets for phlebotomist from 09/09-30/2018 revealed that 1 or 2 staff were working on 7 weekend shifts during this timeframe. The hospital had 5 floor with patient care areas which depended on lab services.


This deficient practice had the likelihood to cause harm to all patients.


Findings include:


During an observation on 10/02/2018 at 2:17 pm., Staff #18 registered Patient #9. The complaints given were a fever and headache. An armband was placed on Patient #9 and she was sent to the waiting room with her mom.

At 2:21 p.m., Patient #9 was taken back to triage. The complaints given was that the child woke up yesterday with a headache, dizzy, burning up, and left eye was red. Nurse practitioner #20 reported that Patient #9 had a possible ear infection and swabbed Patient #20's throat. Staff #19 took Patient #9's temperature and reported it was 100.2 degrees Fahrenheit. At 2:29 p.m., the swab was placed in a lab bag by Staff #19 (triage nurse) and Patient #9 was sent back out to the waiting area. Nurse practitioner #20 reported he was going to put Patient #9 on an antibiotic, ibuprofen, and run a strep screen.

Review of orders dated 10/02/2018 revealed the order was put in at 2:30 p.m. for a Stat ,"Streptococcus A Screen Rapid w/Reflex to Culture".

At 3:23 p.m.,(over 50 minutes after taken) Staff #22 reported the lab had just called and reported that Patient #9 was positive for Streptococcus.


Review of the clinical record of Patient #18 revealed, he presented to the ED on 07/24/2018 with chief complaints of "bodyaches" and "body is hot". Patient #18 was documented as having an elevated temperature of 102.9 degrees Fahrenheit. Some of the following test were ordered and results were as follows:

Complete metabolic panel, Stat, ordered at 10:27 a.m., collected at 10:42 a.m. and the test was completed at 11:18 a.m.

Lactic Acid Stat, ordered at 11:36 a.m., collected at 1:15 p.m. and the test was completed at 1:59 p.m.

Strep A throat, stat, ordered at 11:36 a.m., collected at 12:27 p.m. and the test was completed at 2:33 p.m.

Xray Chest 2 views, Stat, ordered at 11:26 a.m. and completed at 12:20 p.m.

Mononucleosis, Stat, ordered at 11:50 a.m. and completed at 1:48 p.m.


Review of the clinical record of Patient #17 revealed, he was a 55 year old male who presented to the ED on 06/14/2018 for complaints of "numbness/tingling in left arm."

Review of lab orders revealed the following:

CMP Stat
CKMB, Stat
POC Troponin, Stat
CBC, Stat
All of these were documented as being ordered at 12:26 p.m.

CMP Stat collected at 1:03 p.m. and completed at 1:51 p.m.
CKMB, Stat collected at 1:03 p.m. and completed at 1:51 p.m.
POC Troponin, Stat collected at 1:11 p.m. and completed at 1:22 p.m.
CBC, Stat collected at 1:03 p.m. and completed at 1:27 p.m.


During an interview on 10/03/2018 after 9:00 a.m., Staff #12 confirmed the labs. Staff #12 reported that all lab in the ED was stat (immediately) and should be completed within 30 minutes.


LAB STAFFING

The following was stated about lab services from 10/02-03/2018:

"We are having problems with lab, specifically with having enough phlebotomist. They have increased the pay to try to get more."

"Every once in a while they are short in lab staff."

"Sometimes there are delays on BMP."

"There are staffing problems in the lab. Sometimes there is one phlebotomist on the weekends for the entire hospital. When its busy in the ED one person cannot handle everything."


Review of time sheets for the month of September 2018 revealed the following on the weekends:

The phlebotomist shifts were staggered throughout a 24 hour timeframe. On 09/09, 09/15, 09/16, 09/23, and 09/29/2018, there were times when there was one staff member working for the entire hospital.

On 09/22 and 09/30/2018 there were times when there were two staff working for the entire hospital.

Review of an undated list which was provided by administration revealed the hospital had 5 floors which had patient care areas.


LAB TURNAROUND TIMES

Review of lab tracking information revealed the following about lab turn around times:

January

Troponin (Troponin level is a type of blood test used to check for damage to the heart). Was 72 minutes.

Basic Metabolic Panel (BMP) was 82 minutes

Prothrombin Time (PT) A blood clotting test was 66 minutes

Complete Blood Count (CBC) was 69 minutes.

February

Troponin - 65 minutes

Basic Metabolic Panel -74 minutes

Prothrombin Time - 66 minutes

Complete Blood Count - 60 minutes


March

Troponin - 66 minutes

Basic Metabolic Panel -73 minutes

Prothrombin Time - 64 minutes

Complete Blood Count -58 minutes


April

Troponin - 65 minutes

Basic Metabolic Panel - 70 minutes

Prothrombin Time - nothing logged

Complete Blood Count - 60 minutes



May

Information missing.


June

Troponin - 91.8 minutes

Basic Metabolic Panel - 80.3 minutes

Prothrombin Time - 56.5 minutes

Complete Blood Count - 64.5 minutes


July

Troponin - 75 minutes

Basic Metabolic Panel - 76 minutes

Prothrombin Time - 72 minutes

Complete Blood Count - 56 minutes


August

Troponin - 68 minutes

Basic Metabolic Panel - 69 minutes

Prothrombin Time - 53 minutes

Complete Blood Count - 49 minutes


September

Troponin - 66 minutes

Basic Metabolic Panel - 65 minutes

Prothrombin Time - nothing logged

Complete Blood Count - 48 minutes


During an interview on 10/03/2018 after 1:30 p..m., Staff #23 confirmed the numbers and reported they were doing better. When questioned about the timeframe the labs should be completed she said "30 minutes." Staff #23 reported there was no way the troponin could be completed in that timeframe because of the time it took for the equipment to run the test.

Staff #23 reported she had enough phlebotomist. On the weekends, she staffed 3 phlebotomist at all times.The only staff she was short in was medical technologist. Eight medical technologist had retired. Staff #23 reported, she had replaced a few of them and called off three names. Staff #23 provided an email which outlined the staff she needed and the job postings. The following documentation was on the e-mail:

"Due to an ongoing review of all currently approved positions, all job postings have temporarily been removed from the job posting board until the review can be completed this week or next week. During this process, however, the following position for the Lab are up for review and will hopefully be reposted in the near future."
The postings were for one lab tech, one lead medical technologist, three medical technologist, and one phlebotomist.


The turn around times showed it was taking an extended time to obtain the Stat lab results. The lab did not have sufficient staff at all times to provide services for the entire hospital.

Based on record review and interview, the facility failed to identify patients who were at high risk for adverse health consequences upon discharge when discharge planning was not completed in 2 of 3 patients reviewed. The facility failed to make a referral as requested by the physician and the patient for needed hospice and respiratory equipment in 1 (# 3) patient reviewed. The facility failed to complete the discharge planning process in 1 (#5) patient reviewed. Also, the facility failed to follow the facility policy on discharge planning.


This deficient practice had the likelihood to harm all patients who were discharged from the facility.


Findings Include:

PATIENT #3

Review of the patients History and Physical revealed the following:

Patient #3 was a 49-year-old female who had a complicated case. Patient #3 had a history of diastolic heart dysfunction, LVH (Left Ventricular Hypertrophy), pulmonary hypertension, severe obstructive sleep apnea, and diabetes mellitus. The history and physical documentation showed Patient #3 was on hospice for heart failure. The history and physical documentation stated, the hospice nurse noted that Patient #3's leg was becoming more swollen, patient #3 was in more distress from breathing, and she was instructed to go to the hospital. The patient revoked hospice and wanted treatment.

The treatment plan on the history and physical document stated, patient #3 will be started on wound care and IV antibiotics; patient #3 will be continued on oxygen therapy. The plan stated that case management will be asked to assist with transition and placement.


Review of the Case Management discharge planning notes revealed the following:

The note was written by Staff #13 on 3-16-2018 at 10:49 AM

Tentative Discharge Destination: Hospice - Home

Comments:
"3/15/2018 15:15 Sw (Social worker) met with pt. to educate on the role of the sw, to assist with dcp (Discharge planning) and to identify any unmet needs. The pt. lives alone and was on service with hospice services. The Pt. has been on hospice for a year. The pt. is extremely overweight. The pt. told sw that she can ambulate with a walker. The pt. has home oxygen, walker, CPAP, hospital bed, and a wheelchair." The pt. Stated she revocated hospices services because the wound on her leg was getting worse. The pt. stated "I cannot take the pain anymore. I spoke with Dr. Pitt's and she said I could get back with hospice services when I discharge." SW will look into this. DCP is home.


Review of a progress note dated 3-17-2018 revealed the following:

The progress note was completed by the hospitalist. The signature was unreadable. The plan on the progress note stated, "Wound care, ABTS, Pain control, arranging outpatient wound care, Discharge planning."


Review of the discharge summary report dated 3-18-2018 revealed the following:

Follow up appt: pcp (Primary care Physician) in 10 days, phone. Discharge teaching: OUTPT wound care at TMC-SETX. There was no referral back to hospice or arrangements made for oxygen equipment needed. The patient was noted to have chronic moderate dyspnea on the problem summary. There was a notation made that stated,"the patient says the dyspnea is occurring more frequently lately." The patient was discharged on a weekend. There was no notation in the chart that the case manager on call was contacted to inquire about the status of hospice services or respiratory equipment needed.


Review of the transfer/discharge flowsheet dated 3/18/2018 at 4:46 PM showed, patient #3 discharged home with prescription. F/U appointment - pt. to call physician office, wound care. There was no notation of a referral back to hospice or arrangements for oxygen equipment needed.


Review of Respiratory assessment flowsheet dated 3/18/2018 showed the patient was on oxygen at 3 lpm (Liters per minute).


Review of the discharge summary dated 3-18-2018 revealed:

"Discharge Diagnosis:
...Pulmonary Hypertension, Obstructive Sleep Apnea, which is severe ...

Vital Signs:
...Patient #3 had oxygen saturation of 97% on 3 liters of oxygen.

Hospital Course:
...Patient #3 was admitted for IV antibiotics and wound care and chooses to go home without hospice at this time. She does have home CPAP (Continuous positive airway pressure) which she will continue with at home for her severe obstructive sleep apnea."


Patient #3 was readmitted on 4-25-2018 with an admitting diagnosis of "Obtundation and respiratory failure."


Review of the history and physical documentation dated 4/25/2018 revealed the following:

"This is a 49 year old female who evidently has a history of morbid obesity and some right lower leg wound. She was on hospice at home ...
Pt was in her bed. She was very lethargic, was not breathing well ....
She was intubated for airway protection and her respiratory failure."


Review of the Discharge Summary dated 4/25/2018 revealed the following:

Discharge Diagnosis:
"1. Acute on chronic respiratory failure with hypoxia
2.Acute on chronic respiratory failure with hypercapnia ...

Discharge Instructions:
Consult home hospice on discharge ..."

Staff #11 confirmed the above findings.


An interview on 10/3/2018 at 1:20 PM with Staff # 13 revealed the following:

Staff #13 said, she called hospice service on 3-16-2018 (Friday) to inquire about getting Patient #3 back on hospice. Staff #13 said, the hospice service was going to check with the physician and get back to her. Staff #13 said, when she came back to work on 3-19-2018 Patient #3 had been discharged. Staff #13 said, she called Patient #3 to inquire about hospice and respiratory equipment. Staff #13 said, Patient #3 said she would call hospice and asked Staff #13 to call back later because she was tired. Staff #13 said, she did not make any more calls. Staff #13 was asked if these conversations were documented in the patient's medical record. Staff #13 confirmed there was no documentation of the conversations she had with Patient #3 and did not talk with anyone regarding the pending arrangements.


An interview on 10/3/2018 with Staff #24 on 10-5-2018 revealed the following:

Staff #24 said, she was no longer an employee with the hospice service from the complaint. Staff #24 from what she could recall without her case notes, Patient #3 was discharged home without a referral back to hospice. Staff #24 said, Patient #3 had equipment at her house that belonged to hospice. Staff#24 said, Patient #3 refused to give the equipment back because she had no other way to get the equipment she needed. Staff #24 said, the patient did not have a doctor outside of hospice. Staff #24 said, the hospice home health did work with the patient to help her get back on service, but there was no referral to them from the facility at discharge.


An interview with Staff #10, Case Management Director, on 10-3-2018 at 1:55 PM revealed the following:

Staff #10 said, the case management office has someone available 24 hours a day, seven days a week. Staff #10 said, they have case workers that work every Saturday to make rounds and assess needs for the weekend. Staff #10 confirmed she was responsible for the social workers at the facility, and ensuring that quality care was provided.


Review of the facility document titled, "Case management staffing" with an updated date of February 19, 2018 revealed the following:

"Case management representatives are available seven days a week ...

...Discharge planning plays a large role in the continuum of care. Referrals for post-acute hospital care are made by case managers to serve the patient's needs based upon physician order for services and patient choice and request for specific providers.

...Urgent or emergency situations on Saturday, Sunday, and holidays will be addressed by the on call staff. The department manager and the on-all case manager are available via cell phone 24 hours a day ..."


Review of the facility policy titled, "Discharge Planning/Transition of Care" dated with a final approval date of 8/7/2017 revealed the following:

"Definitions:

Discharge Planning: A four step process consistently implemented that includes:

1. Screening of all inpatients to determine which ones are at risk of adverse health consequences post-discharge if they lack discharge planning.

2. Evaluation of the post-discharge needs of patients identified though the screening process or of patients or physicians who request an evaluation.

3. Development of a discharge plan after evaluation or at the request of the patient's physician.

4. Initiation of the discharge plan prior to discharge.

Procedure:

... 6. Case Managers along with other members of the healthcare team and transition coordinator partners will coordinate and facilitate initial discharge plans of transfers/referrals to the following:
e. hospice

7. The results of the discharge planning evaluation will be discussed and documented with the patient or the patient's representative. This includes the patient's rejection of the plan of care formulated from the discharge planning evaluation.

9. Case management staff will initiate and implement the discharge plan and any adjustments to the plan prior to the discharge of the patient. Discharge planning is documented and becomes part of the patient's medical record."



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Review of the clinical record of Patient #5 revealed, she was a 83 year old female who presented to the hospital on 09/28/2018 after a fall at home.

Review of a physician's history and physical documentation dated 09/28/2018 revealed, Patient #5 had a history of chronic atrial fibrillation. Patient #5 lived at home alone with her husband and she tripped over her husband's walker resulting in the fall.

Review of a "Discharge Documentation" dated 10/02/2018, revealed, Patient #5 sustained a right pubic ramus (hip) fracture. Patient #5 was seen by an orthopedic surgeon whose recommendation was for conservative treatment and cautious weight bearing. Patient #5 was started on physical therapy while at the hospital and was able to ambulate the halls and back with walker assistance. Patient #5 would be discharged to senior rehab skilled nursing today for continued physical therapy and rehab..


Review of physician orders revealed the following:

10/01/2018- Consult to Case management- Transition
10/02/2018 - Discharge to Skilled Nursing facility


Review of the record revealed no documentation of a case management assessment or information about preparation for discharge.


During an interview on 10/03/2018 after 11:30 a.m., Staff #21 confirmed the information was missing and she could not find it. Staff #21 reported that case management had another area they documented in and she would have them find it.


During an interview on 10/03/2018 after 12:08 p.m., Staff #'s 25 and 26 (Case management) reported not having documentation of a case management consultation or assessment on the chart at all. Staff #25 reported the case management initial assessment was blank. The discharge planner was out sick for the last 2 days and they were short of staff by 2 people. The orthopedic nurse navigator does not work the weekends and she would be the person setting up the therapy. Staff #25 reported she had done some of the planning on Monday (10/01/2018), talked to Patient #5, and set up therapy at the skilled facility. Staff #25 revealed she did not document talking to Patient #5 nor did she document that Patient #5 was given options of skilled facilities.

Based on observation, interview, and record review, the facility failed to ensure the Emergency Department (ED) was organized in a manner to meet the needs of patients. The facility failed to:

A. ensure registration clerks were trained and had job descriptions which included all of the duties they were performing in the ED. Registration clerks were deciding who went to see the triage nurse and who went to the waiting room. The registration clerks had no written guidance on how to direct patients to triage.

B. ensure patients who were potentially contagious were placed in a room or provided Personal protective equipment (PPE) so other patients would not be exposed. A patient who tested positive for a contagious infection was kept in the waiting room, putting other patients at risk for infection.

C. ensure staff were available to help with the flow of patients through the ED. The facility had a shortage of techs and unit secretaries from 09/19-10/01/2018.

D. ensure patients with Stat (immediate) lab orders were processed timely in 3 of 18 sampled patients (Patient #'s 9, 17, and 18). Some test resulted over an hour after being ordered.

Refer to A tag 1101 for additional information.

Based on observation, interview, and record review, the facility failed to ensure the Emergency Department (ED) was organized in a manner to provide safe care. The facility failed to:

A. ensure registration clerks were trained and had job descriptions which included all of the duties they were performing in the ED. Registration clerks were deciding who went to see the triage nurse and who went to the waiting room. The registration clerks had no written guidance on how to direct patients to triage.

B. ensure patients who were potentially contagious were placed in a room or provided Personal Protective Equipment (PPE) so other patients would not be exposed. A patient who tested positive for a contagious infection was kept in the waiting room, putting other patients at risk for infection.

C. ensure staff were available to help with the flow of patients through the ED. The facility had a shortage of techs and unit secretaries from 09/19-10/01/2018.

D. ensure patients with Stat(immediate) lab orders were processed timely in 3 of 18 sampled patients (Patient #'s 9, 17 and 18). Some test resulted over an hour after being ordered.

This deficient practice had the likelihood to cause harm to all patients.


Findings include:


REGISTRATION

During an observation of the registration process on 10/02/2018 after 2:00 p.m., Staff #18 reported that she gets the patients initial information and puts the information into the computer. If the patients had chest pain, shortness of breath, stroke, or was critical, she picked up the phone and called the nurse to let them know. If not, the patient went to the waiting area until they could be triaged. When questioned if she had a list of conditions which outlined when to call the charge nurse or when to send the patient to the waiting room she replied "no".


Review of the job description for an "ADMITTING REGISTRAR" revealed no documentation of the clerks being responsible for assisting the patients to the triage process.

Review of the facility's policy named "Standards of Practice: Emergency Department" dated 05/08/2018 revealed the following:

STANDARD 1:

Upon presentation to the Emergency Department, the Emergency Department Triage RN should attempt to (1) screen the patient (2) determine their Emergency Severity Index classification; and, refer to the physician as is appropriate and in as expedient a manner as possible


TRIAGE/ MEDICAL SCREENING PROCESS

During an observation on 10/02/2018 at 2:17 pm., Staff #18 registered Patient #9. The complaints given were a fever and headache. An armband was placed on Patient #9 and she was sent to the waiting room with her mom.

At 2:21 p.m., Patient #9 was taken back to triage. The complaints given was that the child woke up yesterday with a headache, dizzy, burning up, and left eye was red. Nurse practitioner #20 reported that Patient #9 had a possible ear infection and swabbed Patient #20's throat. Staff #19 took Patient #9's temperature and reported it was 100.2 degrees Fahrenheit. At 2:29 p.m., the swab was placed in a lab bag by Staff #19 (triage nurse) and Patient #9 was sent back out to the waiting area. Nurse practitioner #20 reported, he was going to put Patient #9 on an antibiotic, ibuprofen, and run a strep screen. Patient #9 was observed to lay down in chairs in the waiting area wrapped in a blanket. Staff did not give Patient #9 any kind of mask to wear to prevent exposure to other people in the waiting room.

At 2:45 p.m., Patient #9 was still laying in the waiting area wrapped in a blanket.

At 3:08 p.m., Staff #9 gave Patient #9 some ibuprofen and her mom was instructed to remove the blanket off the patient. Staff #9 provided the mom with a sheet to wrap Patient #9 in. Patient #9 was still in the waiting area.

At 3:23 p.m., (over 50 minutes after the specimen was taken), Staff #22 reported, the lab had just called and reported that Patient #9 was positive for Streptococcus.

Review of "Patient Education Instructions" dated 10/02/2018 at 4:21 p.m., revealed the following:

"..Pharyngitis:Strep Confirmed (Child)

Pharyngitiis is a sore throat. Sore throat is a common condition in children. It can be caused by an infection with the bacterium streptococcus. This is commonly known as strep throat ....Children with strep throat are contagious until they have been taking an antibiotic for 24 hours."


During an interview on 10/03/2018 after 9:00 a.m., Staff #4 and #12 confirmed that Patient #9 should not have been placed back into the waiting area. Staff #4 reported, the staff had been talked to about using the fast track area inappropriately. They were putting patients in the waiting area when they could place them in a room in the back. They were saving rooms in the back just in case they had emergencies that came in. Staff #4 reported, they were using extra technicians to help with the staffing. There would be a technician in the back and one in triage to help. The tech up front would help the triage nurse out.



STAFFING

Review of ED staffing numbers from 09/19-10/01/2018 and the staffing matrix revealed the following:

The facility was short technicians on 09/19, 09/21, 09/22, 09/23, 09/24, 09/26, and 09/27/2018. Some days there was one scheduled and others there was no tech scheduled.

The facility was short a unit secretary on 09/19, 09/24, 09/27, 09/28, 09/29, 09/30, and 10/01/2018.

Staff #12 confirmed the shortages.



LAB TEST IN THE ED


Review of the clinical record of Patient #18 revealed, he presented to the ED on 07/24/2018 with chief complaints of "bodyaches" and "body is hot". Patient #18 was documented as having an elevated temperature of 102.92 degrees Fahrenheit. Some of the following test were ordered and resulted as follows:

Complete metabolic panel, Stat, ordered at 10:27 a.m.,collected at 10:42 a.m. and the test was completed at 11:18 a.m.

Lactic Acid Stat, ordered at 11:36 a.m., collected at 1:15 p.m. and the test was completed at 1:59 p.m.

Strep A throat, stat, ordered at 11:36 a.m., collected at 12:27 p.m. and the test was completed at 2:33 p.m.

Xray Chest 2 views, Stat, ordered at 11:26 a.m. and completed at 12:20 p.m.

Mononucleosis, Stat, ordered at 11:50 a.m. and completed at 1:48 p.m.



Review of the clinical record of Patient #17 revealed, he was a 55 year old male who presented to the ED on 06/14/2018 for complaints of "numbness/tingling in left arm."

Review of lab orders revealed the following:

CMP Stat
CKMB, Stat
POC Troponin, Stat
CBC, Stat

All of these were documented as being ordered at 12:26 p.m. .


CMP Stat collected at 1:03 p.m. and completed at 1:51 p.m.

CKMB, Stat collected at 1:03 p.m. and completed at 1:51 p.m.

POC Troponin, Stat collected at 1:11 p.m. and completed at 1:22 p.m.

CBC, Stat collected at 1:03 p.m. and completed at 1:27 p.m.


During an interview on 10/03/2018 after 9:00 a.m., Staff #12 confirmed the labs. Staff #12 reported that all lab in the ED was stat (immediately) and should be completed within 30 minutes.