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Based on observation, interview and document review, the facility's Governing Body did not oversee and approve a portion of the Emergency Department (ED) waiting area to be utilized as a patient care area and failed to develop and initiate policies and procedures to clarify what type of patient care was approved to be done in the area.

Findings include:

On 01/11/2023 at 12:00 PM, part of the Emergency Department (ED) waiting room was sectioned off labeled the "Results Pending Waiting Area (RPWR)." The RPWR area was approximately 20 feet by 26 feet which opened to a corridor which connected main ED waiting area to the walkway leading to the hospital's main entrance.

The area had approximately 15 regular chairs in a portioned off alcove area and two large lounge chairs in the corridor next to the wall. There was signage on the wall just above the chairs indicating RPWR chair 1 through 10. There were two vending machines in the corridor across from the portioned off alcove area designated as the RPWR area for hospital and ED waiting room patients and visitors. There were four portable oxygen machines in the RPWR area. There were three chairs in the RPWR area with used blankets on top of the chairs. Next to the lounge chairs located in the in the corridor, was an intravenous (IV) pole with a used IV bag and tubing. There was one hand sanitizer dispenser in the area and no sink. There was no biohazard container in the area.

On 01/11/2023 at 12:00 PM, the ED Director indicated patients were seen in the triage area inside the ED and sent to the RPWR to wait for results. The ED Director indicated patients could be sent to the RPWR area with IV solutions being infused while waiting for reevaluation from the medical provider. The ED Director indicated medications could be administered in the RPWR area and patients could be discharged from the area. The ED Director took the used blankets left on the three RPWR chairs and indicated the area would be cleaned by housekeeping. There was no housekeeping staff in the area.

On 01/11/2023 at 12:00 PM, in the main ED waiting room Patient #11 was observed receiving IV infusion treatment, the patient was not in the RPWR area. The ED Director did not know why the patient was not placed in the RPWR area. Other people were sitting around the patient waiting to be seen or were family or friends waiting with other patients.

On 01/11/2023 at 12:15 PM, the RPWR area had four people sitting in the area. There was no barrier to keep family or other patients waiting to be triaged from entering and sitting in the area. There was no privacy in the RPWR area for patients receiving IV treatments, receiving medications, or being discharged from the area. There was no barrier to keep people from the main ED waiting room overflowing to the RPWR area if there was no other seating in the main ED waiting room.

On 01/11/2023 at 12:30 PM the ED Director indicated there were no approved policies to identify the following:

-What treatments or procedures could be done in the RPWR area, such as IV antibiotic treatments, IV hydration, electrocardiograms, or portable x-rays.
-What medications could be given or not given in the area, such as oral, inhalation or injectable's.
-Who could be discharged in the area with no privacy.
-Who was assigned to the area for cleaning after treatments were completed and a patient had left.
-Who was assigned to the area to check on patients receiving treatments.
-How to allow privacy for patients receiving treatments
- How to deter people walking through the area to go to the main hospital, and to use the vending machines
- How to stop the overflow of people in the main waiting room and prevent entrance into the RPWR area to find an open seat, and
- How to re-route security staff going through the RPWR area to enter their office which was inside the RPWR area.

On 01/12/2023 at 3:00 PM, the Chief Nursing Officer (CNO) who also presided over the Governing Body (GB), indicated the GB did not discuss and approve the "Results Pending Waiting Area" in the emergency department waiting room. There were no policies or procedures to determine criteria on which patients should be placed in the area, treatment provided in the area, medication approved to be administered in the area, infection control processes and possible discharge process implemented in the area.

The hospital was unable to provide a policy and procedure related to the development and use of the RPWR area.

Based on interview and record review, the facility failed to reassess laboratory magnesium levels and follow the physician orders for a proper discharge of a patient whose Magnesium blood levels were not within normal range for 1 of 31 sampled patients (Patient 7).

Findings include:

Patient 7 was admitted on 02/05/2022 and discharged on 02/07/2022 with diagnoses including hypokalemia and hypomagnesemia.

A physician order dated 02/05/2022 indicated to administer Magnesium Sulfate 2 grams in 50 milliliter solution.

There was no documented evidence the Magnesium Sulfate was administered,

A physician order dated 02/07/2022 indicated to discharge the patient home if the potassium level was greater than 3.5 mmol/L (millimoles per liter) and the magnesium level was greater than 1.8 mg/dL (milligrams per deciliter).

The last Magnesium level obtained on 02/07/2022 at 12:43 PM was 1.6 mg/dL.

The patient was discharged home at 02/07/2022 at 11:59 PM.

There was no documented evidence the Magnesium level was greater than 1.8 to discharge the patient.

On 01/10/2023 in the afternoon, the Performance Improvement Manager indicated the patient was discharged even though the Magnesium level was below 1.8 mg/dL, and the 2 grams of Magnesium Sulfate solution was not administered. The physician orders were not followed.

There was no documented evidence the physician was notified of the low magnesium level reported at 12:43 PM or the Magnesium Sulfate was not administered as ordered to determine if another dose of Magnesium was to be given prior to discharge or if it was safe to discharge the patient with a low Magnesium level.

Based on observation, interview and document review, the facility failed to clarify how they were to utilize an area of the Emergency Department (ED) waiting room as a patient care area.

Findings include:

On 01/11/2023 at 12:00 PM, part of the Emergency Department (ED) waiting room was sectioned off labeled the "Results Pending Waiting Area (RPWR)." The RPWR area was approximately 20 feet by 26 feet which opened to a corridor which connected main ED waiting area to the walkway leading to the hospital's main entrance.

The area had approximately 15 regular chairs in a portioned off alcove area and two large lounge chairs in the corridor next to the wall. There was signage on the wall just above the chairs indicating RPWR chair 1 through 10. There were two vending machines in the corridor across from the portioned off alcove area designated as the RPWR area for hospital and ED waiting room patients and visitors. There were four portable oxygen machines in the RPWR area. There were three chairs in the RPWR area with used blankets on top of the chairs. Next to the lounge chairs located in the in the corridor, was an intravenous (IV) pole with a used IV bag and tubing. There was one hand sanitizer dispenser in the area and no sink. There was no biohazard container in the area.

On 01/11/2023 at 12:00 PM, the ED Director indicated patients were seen in the triage area inside the ED and sent to the RPWR to wait for results. The ED Director indicated patients could be sent to the RPWR area with IV solutions being infused while waiting for reevaluation from the medical provider. The ED Director indicated medications could be administered in the RPWR area and patients could be discharged from the area. The ED Director took the used blankets left on the three RPWR chairs and indicated the area would be cleaned by housekeeping. There was no housekeeping staff in the area.

On 01/11/2023 at 12:00 PM, in the main ED waiting room Patient #11 was observed receiving IV infusion treatment, the patient was not in the RPWR area. The ED Director did not know why the patient was not placed in the RPWR area. Other people were sitting around the patient waiting to be seen or were family or friends waiting with other patients.

On 01/11/2023 at 12:15 PM, the RPWR area had four people sitting in the area. There was no barrier to keep family or other patients waiting to be triaged from entering and sitting in the area. There was no privacy in the RPWR area for patients receiving IV treatments, receiving medications, or being discharged from the area. There was no barrier to keep people from the main ED waiting room overflowing to the RPWR area if there was no other seating in the main ED waiting room.

On 01/11/2023 at 12:30 PM the ED Director indicated there were no approved policies to identify the following:

-What treatments or procedures could be done in the RPWR area, such as IV antibiotic treatments, IV hydration, electrocardiograms, or portable x-rays.
-What medications could be given or not given in the area, such as oral, inhalation or injectable's.
-Who could be discharged in the area with no privacy.
-Who was assigned to the area for cleaning after treatments were completed and a patient had left.
-Who was assigned to the area to check on patients receiving treatments.
-How to allow privacy for patients receiving treatments
- How to deter people walking through the area to go to the main hospital, and to use the vending machines
- How to stop the overflow of people in the main waiting room and prevent entrance into the RPWR area to find an open seat, and
- How to re-route security staff going through the RPWR area to enter their office which was inside the RPWR area.

On 01/12/2023 at 3:00 PM, the Chief Nursing Officer (CNO) who also presided over the Governing Body (GB), indicated the GB did not discuss and approve the "Results Pending Waiting Area" in the emergency department waiting room. There were no policies or procedures to determine criteria on which patients should be placed in the area, treatment provided in the area, medication approved to be administered in the area, infection control processes and possible discharge process implemented in the area.

The hospital was unable to provide a policy and procedure related to the development and use of the RPWR area.