HospitalInspections.org

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Based on observation and interview the facility failed to ensure patient privacy for Emergency Department patients receiving care. This was evident in five (5) patient observations (Patients #1, #2, #3, #4 and #18).

Findings:

Observations on 01/21/15 between 10:15AM and 12:00 Noon revealed Patients #1, #2, #3, #4 and #18 presented to the Emergency Department's "External Triage Area" located in the Emergency Department Entrance between three (3) Waiting Areas, where Staff #21 obtained the patients' names, addresses, telephone numbers and chief complaint in the presence of the other patients and visitors.

Then, Patients #1, #2, #3, #4 and #18, still in the "External Triage Area" in full view and within hearing distance of the other patients and visitors, met with Staff #22 who obtained the patients' chief complaint, presenting symptoms, past medical histories and current medication lists.

Staff #22 was observed opening Patient #4's shirt, then examining the child's chest and neck in the presence of other patients and visitors.

The staff member also opened Patient #3's jacket to assess his shoulder in the presence of the other patients and visitors.

An interview with Staff #1 on 01/22/15 at approximately 10:00AM revealed they were aware of the privacy issues at the "External Triage Area". There are plans, in the infancy stage, to renovate the Emergency Department Triage Waiting Room into a Triage Area.

Review of the Policy titled "Patient Privacy" dated 07/17/14, documented all patients presenting to the Emergency Department shall be assured that all reasonable steps will be taken to maintain their privacy.
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Based on observation, interview and record review, the facility failed to ensure that Restraints were safely applied in one (1) out of one (1) observation (Patient #6).

Findings:

Medical Record documents that Patient #6 is a 72-year-old male was admitted on 12/30/14 and in bilateral wrist restraints to prevent pulling out tubes and Intravenous lines.

On 01/22/15 at 2:20PM on 7 West, Patient #6 was found with his right wrist tied with a knot as opposed to a slip knot.

Interview was conducted on 01/22/15 at 2:20PM with Staff #13 who stated that the patient should have had the wrist secured with a slip knot and not a knot for the patient's safety.

The Policy titled "Application of Two (2) Point (Wrist) Restraint", dated 01/14, documents to "attach webbing strap to bottom portion of bed frame secure with a slip knot (quick release)".
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Based on record review and interview, the facility failed to ensure that the Interdisciplinary Care Plan reflected the patient's nutritional status as evidenced by not updating the Care Plan and address the nutritional issues of a severely compromised patient (Patient #12).

Findings:

Review of the Medical Record for Patient #12 documents that the patient is a 79-year-old female who was admitted on 10/05/14 at 13:30 with a chief complaint of Altered Mental Status and possible onset of Dementia.

Review of the Record documented that the patient was observed having problems swallowing and on 10/08/14 a Physician documented that the patient had "submental tenderness to palpation".

The Chart was reviewed with Staff #12 which revealed that the patient was ordered NPO (nothing by mouth) except medications on Wednesday 10/08/14 and ordered a repeat Swallow Evaluation.

On 10/09/14 the patient failed the Speech / Swallow Test.

The Medical Record lacked a Diet Order for pureed food until 10/13/14. The patient was NPO from 10/08/14 until the following Monday on 10/13/14.

Record review revealed that the patient was weighed on admission at one hundred forty (140) pounds. There is no further weight documentation for the remaining hospital visit. The patient was discharged to a nursing facility on 10/16/14.

The Interdisciplinary Plan of Care dated 10/06/14 failed to address the patient's nutritional status including the patient's weights and being NPO from 10/08/14 to 10/13/14.

The Department of Nursing Policy for the scope of service on the 7th Floor, dated 07/2014 documents that "the complex care of this mixed population requires a cohesive Interdisciplinary Team which consists of the Nurse Manager, Assistant Nurse Managers, Staff RNs, Staff PCAs, Physicians, Hospitalists, NPs, Respiratory Therapists, Skin Integrity Nurses, Food and Nutrition, Social Work, Case Management ... ".

This Policy also documents that " Required Competencies and Training for this Unit beyond general Medical / Surgical Competencies include ... maintaining nutrition and skin integrity for the severely compromised patient ... ".

The Clinical Nutrition Policy titled " Weighing the Patient", dated 10/2012, documents the purpose of weighing a patient is to "estimate the nutritional status of the patient".

Scales utilized on the Nursing Units include standard upright, electronic and bed scales.

"All weights should be actual NOT stated."

"Patient will be weighed on admission to the hospital and then once a week."

"Required periodic weights are recorded in the Vital Signs Section / Flow Sheet."

An interview conducted with Staff #20 on 01/23/15 at 10:00AM revealed that there is an Interdisciplinary Team that meets daily at the Nursing Station prior to rounds. She stated that a Dietitian was not always on the Team.

On 01/23/15 at 11:00AM Staff #19 stated that the "Physician is responsible and knows the patient is not eating. We are documenting assessment in Sunrise (Electronic Medical Record). They (referring to Physicians) should be going into our Evaluation Section."

An interview with Staff #14 on 01/23/15 at 1:00PM revealed that there was a Weight Book on the 7th Floor in which they recorded weights on the patients. This book was present but there were no weights in the book from October and were not produced during the survey visit.
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Based on interview, Medical Record review and review of other documents, it was determined that the facility did not: a) implement the Emergency Department (ED) Policies / Protocols to prevent patient elopement by failing to assess patients at risk for elopement, following Physician's Orders to prevent elopement, implementing procedures when an elopement has been identified, and completing an Incident Report identifying the investigation of the occurrence; this was evident in two (2) out of three (3) Medical Records reviewed (Patients #10 and #17), and b) review and update the Policies for Triage and Intake.

Findings

a) Review of the Medical Record documents that Patient #10 is a 64-year-old male with a history of Dementia who presented to the Emergency Department on 11/13/14 at 3:13PM via ambulance. The patient had transferred from a Skilled Nursing Facility (SNF) on a stretcher accompanied by personnel from Emergency Medical Services (EMS) for evaluation of left-sided groin swelling and pain. The pre-hospital Patient Care Report (PCR) and SNF Face Sheet and Resident Transfer Sheet were in the Medical Record. The SNF Sheet noted the patient had diagnoses of Dementia and Seizures and had a known history of wandering. The patient had a Wander Guard safety alarm device in place on his wrist. The patient had a current Physician's Order to receive Aricept medicine daily for Dementia.

The Triage Nurse (Staff Member #3) documented at 15:30 (3:30PM) that the patient's chief complaint was groin pain. The patient was not assessed as an elopement risk.

The ED Physician (Staff Member #5) documented in the "History of Present Illness" Section the patient with chronic inguinal non strangulated hernia of several months. The physical exam documented the patient was awake and appropriate for situation. Alert and oriented to person, place and time. No apparent risk to self or others. The Physician scheduled an outpatient appointment for 01/07/15 at 1:15PM for a Surgical Clinic Consult. The Physician documented at 18:51 (6:51PM) that the Treatment Plan was to discharge the patient to an Assisted Living Facility.

On 11/13/14 at 7:08PM, the ED Nurse (Staff Member #4) documented the patient's disposition from the ED as "home with spouse via ambulance".

During an interview conducted on 01/22/15 at 2:33PM Staff #6 stated "he received a phone call from the Nursing Home Supervisor on 11/13/15 in the evening inquiring about Patient #10's disposition. Stated he notified the Nursing Home Supervisor that Patient #10 had left and was no longer in the ED. When asked by the Surveyor if he reported this incident to anyone, he confirmed he did not report this incident. Stated "I thought the nursing home was handling it and looking for the patient". The staff member verified that the Elopement Policy was not initiated. When asked if the facility had any further responsibility for Patient #10 after the elopement was confirmed and reported by the nursing home to the Police, he replied he wasn't sure. He confirmed that he had failed to document a Note in Patient #10's Medical Record and/or complete an Incident Report.

An interview with Staff #9 on 01/23/15 at 10:50AM verified that there was no record found of an ambulance being dispatched to the facility to pick up Patient #10 from ED for return transfer to the nursing home. There was no record of the facility's ambulance request call for Patient #10 for return / transfer to the nursing home.

An interview with Staff #9 by New York State EMS Staff confirmed that the patient was found at the Freeport Train Station on 11/14/14 and later that same day was taken to an ED at another facility.

During an interview with Staff #4 on 01/23/15 at 10:50AM, the staff member, who provided the Discharge Instructions to the patient and documented the inaccurate disposition of the patient, stated he did not recall the patient or the incident.
The Medical Record lacked any information regarding the elopement of Patient #10. The facility failed to implement the Physician' Order to obtain an ambulance to transfer Patient #10. No evidence of an Incident Report or investigation was provided regarding the elopement.

Review of the Medical Record documented that on 12/20/14 at 8:49PM Patient #17 was brought into the ED by the Police with a chief complaint of alcohol intoxication. The EMS pre-hospital Patient Care Report documented the patient was found lying in a street attempting suicide by running into moving traffic and he required monitoring at the nearest facility. The patient was triaged at 8:55PM and assessed as Spanish speaking, homeless, and restless. The patient was not assessed as an elopement risk.

The ED Resident examined the patient and ordered a one to one (1:1) constant observation with Bilateral Wrist Restraints for extreme disorganization, inability to follow direction and wandering. The ED Physician documented on 12/21/14 at 12:11AM that "at about 11:00PM we noted the patient had eloped. Despite the fact that a 1:1 and Restraints were ordered, and to my knowledge never done. I had informed the RN about these Orders about a half hour (1/2) prior and told Security Guard about the Restraints at approximately the same time".

The Incident Report dated 12/23/14 documented that an Elopement Assessment was not completed and the Nurse failed to follow the Orders for the 1:1 and Restraints for Patient #17.

During an interview with Staff #10 on 01/23/15 at 3:30PM, the staff member stated that the investigation of the elopement of Patient #17 was not completed.

Review of the ED Nursing Policy / Procedure titled "Patient Elopement / Missing Patient" dated 11/2014 states:

a. Purpose: To establish a plan in locating a missing patient and assist in the safe return of the patient to the appropriate disposition.

b. Definition: Elopement is defined as the unauthorized absence of an admitted patient, who is incapable of adequately protecting himself or herself and who departs unsupervised or undetected, from the boundaries of the Patient Care Unit.

c. Definition: A missing patient is defined as a patient found missing from a Care Area without staff knowledge or permission.

d. Policy: "All patients who are at risk for elopement and require Medical and/or Nursing care will be identified as early as possible. Risk for elopement will be assessed upon admission and subsequently if triggered by the evidence of any risk factors for elopement identified during routine assessments. If a patient is determined to be missing, then 'CODE FLIGHT' procedures should be implemented to locate the patient."

e. Scope: "This policy applies to all members of Nassau University Medical Center's work force..."

f. Procedure - Identify Patients at Risk for Elopement:
i. Patients presenting to the Emergency Department, who are at risk for elopement, will be identified and appropriate precautions taken to ensure their safety.
ii. The Registered Nurse's Initial and Ongoing Assessment will document any abnormal findings in the Medical Record.
iii. Patients considered at risk for elopement include but are not limited to:
1. Previously diagnosed with cognitive impairment, i.e., Alzheimer's Disease, Brain Trauma, Dementia, Memory Impairment...
2. Under the influence of drugs and/or alcohol
3. Presenting with a psychiatric complaint
4. The patient has a known history of elopement

g. Procedure - For Patients at Risk
i. Patients with a pertinent history, or current assessment which presumes them to be at high risk for elopement, will be disrobed immediately upon arrival to their geographical location, by Nursing Staff. They will be placed in a conspicuous location, whenever possible, and placed in a hospital gown.
ii. When possible, patients will be placed close to Nurses' Station.
iii. The Health Care Practitioner will be notified of the elopement risk if further medical evaluation is necessary.
iv. RN and Health Care Practitioner may consider transfer to Q15 Minute Observation Unit if bed is available, or placed on a one to one, depending on individual assessment.
v. Document the date patient identified as an elopement risk on the Patient Safety Information Summary.

h. Procedure - For an Eloped Patient: Code Flight Procedure
i. Upon identification of an eloped patient, the staff will search the Unit thoroughly, including bathrooms. If the patient is not found, the Nurse should immediately call 23131 (Security) and have a "CODE FLIGHT" announced overhead with the location.
ii. Security will conduct a search of common and support areas of the facility, including food service areas, corridors, lobbies, lounges, public washrooms, stairwells, exit doors, roof tops, parking areas and the grounds.
iii. If immediate search of grounds proves unsuccessful, Security will notify Nurse Manager or Supervisor. Security will then notify Local Authorities at the request of the Clinical Staff.
iv. Nurse Manager or Nursing Supervisor will notify the covering Health Care Practitioner for the patient providing the current status of the search.
v. Patients' designated representatives will be notified by either Health Care Practitioner, Nurse Manager or Nursing Supervisor that patient has eloped, the status of the investigation including but not limited to who has been contacted, and will be documented in the record.
vi. An Incident Report will be generated.

i. Procedure - If the Eloped Patient is not Located on the Hospital Property after the Initial Search
i. All notifications and outcome should be documented in the patient's Medical Record

j. *Procedure - For Missing Patients:
i. Attempt to contact the patient or their designated representative.
ii. Contact Nursing Leadership and initiate an Incident Report.

Emergency Department Policy / Procedure titled "Security Matters: Patients who are Elopement Risks" dated 07/16/2014 states:
a. Policy: "The following procedure is for Emergency Department (ED) patients who do not have capacity for medical decision making but wish to leave the Emergency Department."
b. Procedure:
i. Patient who is elopement risk shall have all clothing and property removed and cataloged per NHCC Policy RI-140 titled Patient Valuables, Clothing and Medications.
ii. Patient should be placed on one-to-one constant observation and dressed in a green colored gown until he/she is discharged or deemed capable of making medical decisions.
iii. If patient leaves the ED without being discharged, hospital Security should be notified and an Incident Report completed.
iv. Patient's family Health Care Proxy / next of kin / family should be notified, if possible, by ED staff of patient's premature departure and necessity of patient's return to the ED. This should be documented in patient's Medical Record.

During interview with Staff Members #1, #2 and #10 on 01/23/15 at 3:30PM, Staff #10 stated that "our ED is very busy and someone can get lost in the crowd".

b) Review of the Policy titled "Triage -Emergency Department" dated 07/18/14 documented patients will be identified by the Triage Provider (example: Registered Nurse, Physician's Assistant) as immediate, emergency, urgent, semi-urgent, or non-urgent using the Emergency Severity Index 5 Level Triage System. Patients may be seen by a "Greeter Nurse" in the Emergency Department Waiting Room. External Triage Area: patients will sign in at the Registration Desk in the Emergency Department Waiting Room. Their name and chief complaint will be entered into the electronic system and populate the Patient Tracking Board. When there is a "Greeter Nurse" present, the patient will immediately speak with the Nurse. The Nurse may ask additional questions to determine the Triage Category (ESL Level 1-5). When there is no "Greeter Nurse all patients will be seen by the "External Triage Nurse". Each time this Nurse calls a patient into the Triage Room he/she will scan the Waiting Area to observe the patients present and respond to any obvious impending emergency.

Review of the Policy titled "Initial Intake" dated 07/11/14, documented "all patients who enter as "walk-in" status will be met by a member of the Clinical Staff (Greeter) who will obtain the initial complaint and screen for conditions which may require emergent intervention, such as: chest pain .... *If any of the above are present as a patient complaint - a Nurse or Physician's Assistant is to be notified immediately. The Waiting Room Patient Access Staff will complete quick registration process which will generate a patient Medical Record Number and Emergency Department visit with required patient information (patient name, age, sex date of birth) and chief complaint. A band will be attached to the patient's wrist for identification."

The "Initial Intake" Policy documents a Licensed Practitioner will obtain the chief complaint from the "walk-in" patient on arrival to the Emergency Department. However, the "Triage - Emergency Department" Policy has the patient signing in at the Registration Desk, and being seen by a "Greeter Nurse" in the Emergency Department Waiting Room. Also when there is no "Greeter Nurse" all patients will be seen by the "External Triage Nurse". However, the "Greeter Nurse" works in the "External Triage Area".

During an interview with Staff #1 on 01/22/15 at 3:00PM the staff member agreed the Policies were contradictory and stated they needed to be updated.
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Based on observation, staff interview and record review, the facility failed to have adequate qualified staff in the Emergency Department (ED) as evidenced by the facility's failure to ensure that: a) a Licensed Practitioner obtained the chief complaint from the "walk-in" patients on arrival to the Emergency Department (Patients #1, #2, #3, #4 and #18), and b) a "walk-in" patient was appropriately questioned regarding her symptoms to ensure timely treatment (Patient #11).

Findings:

a) Observations on 01/21/15 between 10:15AM and 12:00 Noon revealed Patients #1, #2, #3, #4 and #18 presented to the Emergency Department "External Triage Area" where they were greeted by a "Patient Access Person," a non-clinical person, Staff #21 who obtained the patients' names, addresses, telephone numbers and chief complaint. The staff member entered the information into the computer, placed a bracelet on the patients' arms, and then directed the patients to the Waiting Room.

During an interview at 10:45AM with the "Greeter Nurse" Staff #22 she stated her responsibilities include to assign the Triage Level 1-5. Staff #22 stated "the Triage Nurse takes the patient's vital signs and auscultates their lungs. I bring patients back to the Triage Area or Fast Track. I just went to see a patient in the Waiting Area. Her chief complaint was her toe. I assessed her toe and moved her to Fast Track so her toe could be assessed by the PA (Physician's Assistant). They are registered first, then I see them. I also perform blood sugar tests in the back. I bring the patients back to the Triage Room behind the electronic metal doors (approximately forty-two {42} feet from the "External Triage Area" and behind electronic metal doors that do not have a visual panel and requires card access for entry)."

Observation at 10:58AM revealed Patient #1, with labored breathing, presented to Staff #21, a non-clinical person, at the "External Triage Area". Staff #21 began the quick registration process. The patient's information was in the system and she verified the patient's information with him. Patient #1 handed her his Driver's License. When she asked him for his chief complaint, he replied "chest pain and difficulty breathing". Staff #21 replied "I'll register you fast" and continued typing and the registration process. She did not immediately notify the Nurse of the patient's emergent status.

The Surveyor immediately notified the "Greeter Nurse" Staff #22, who was in the Emergency Department Waiting Room talking with a patient, of Patient #1's emergent status. Staff #22 immediately questioned Patient #1 regarding his chief compliant, chest pain and difficulty breathing, placed him in a wheelchair, and wheeled him to "Internal Triage".

During an interview at 11:11AM with Staff #21, the non-clinical person, she stated I do a "quick registration" on the patients who present to the Emergency Department. I obtain the patients' names, addresses, telephone numbers and chief complaint. I enter the information into the computer and place a bracelet on the patients' arms. If a "Greeter Nurse" is present I direct the patient to the "Greeter Nurse". If the "Greeter Nurse" is not here I call back to Triage to notify the Nurse that "Patient so and so" and their symptoms i.e. chest pain, difficulty breathing, bleeding, asthma attack, something urgent and patient needs to get back to the Triage Area. A cold or fever can wait. Staff Member #21 stated she was instructed about emergent patients that should go back to the Triage Area by my Supervisor when I was training for the position. She also stated "you use common sense to determine the urgency of the patients' needs".

At 11:35AM Staff #22 "Greeter Nurse" was asked what she was doing in the Main Emergency Department, approximately one hundred thirty-five (135) feet from the "External Triage Area" and behind electronic metal doors that do not have a visual panel and requires card access for entry. She replied "bringing the License back to Patient #1. The "External Triage Area" was without a clinical person and had a non-clinical person greeting patients presenting to the Emergency Department.

On 01/22/15 at 9:15AM an interview with Staff #2 revealed it is the expectation of the "Greeter Nurse" to assess patients in the Waiting Room, bring patients to Fast Track and "Internal Triage" and perform blood sugar testing in the back. This would leave the "External Triage Area" without a Nurse, allowing Emergency Department patients to present to access staff (non-clinical person) who would obtain the chief complaint and direct the patient flow.

Review of Patient#1's Medical Record revealed on 01/21/15 the patient presented to the Emergency Department with a chief complaint of chest pain radiating to the left shoulder and shortness of breath. An Echocardiogram revealed Atrial Fibrillation, Left Bundle Branch Block and a heart rate of 127. The patient had a differential diagnosis of Abdominal Aortic Aneurysm, Unstable Angina, and Myocardial Infarction and was admitted to CCU. A Transthoracic Echocardiogram revealed a left ventricular ejection fraction of 20%.

Review of the Policy titled "Initial Intake" dated 07/11/14, documents "all patients who enter as "walk-in" status will be met by a member of the clinical staff (greeter) who will obtain the initial complaint and screen for conditions which may require emergent intervention, such as: chest pain ....* If any of the above are present as a patient complaint - a Nurse or Physician's Assistant is to be notified immediately. The Waiting Room patient access staff will complete quick registration process which will generate a patient Medical Record Number and Emergency Department visit with required patient information (patient name, age, sex date of birth) and chief complaint. A band will be attached to the patient's wrist for identification."

On 01/21/15 at 2:30PM Staff #10 was made aware of the above.

b) Observation on 01/22/15 at approximately 4:15PM revealed Patient #11, with a cloth covering her mouth, presented to the Emergency Department "External Triage Area" accompanied by a female companion. The female companion informed the "Greeter Nurse" Staff #22 that the patient does not speak English and that the patient asked her to interpret for her. She stated that the patient took a Chinese medication that she "bought off the street" and is having an allergic reaction to it. Staff #22 requested the name of the medication and the time the patient took the medication. The interpreter stated she took the medication during the day, that she did not know the name of the medication, that they have the box of medication and handed it to Staff #22. Staff #22 asked the patient to remove the cloth covering her mouth. When the patient removed the cloth from her mouth Staff #22 stated "your lips are swollen". Staff #22 directed the patient to the Registrar.

As the Registrar began the registration, the interpreter, in a loud voice, stated to Staff #22 that "her tongue is swollen, she can't swallow, her neck feels like it is swelling". Staff #22 stated "you can go straight back". She called the Triage Nurse via the telephone and told her to send a PCA with a wheelchair. The patient was placed in a wheelchair and wheeled back to Triage.

At that time Staff #22 was interviewed. She was asked about the evaluation and why she did not question the patient about her ability to breathe or swallow and how her neck felt. She shrugged and "I sent her right back".

An interview with Staff #23, Triage Nurse, at approximately 4:20PM revealed by the end of Triage, the patient's "tongue was more swollen. I sent her to the Resuscitation Room for treatment."

On 01/23/15 at 10:25AM an interview with Staff #2 revealed when the interpreter notified the "Greeter Nurse" that the patient's tongue was swollen, that she could not swallow and her neck was swelling, it would have been better for the "Greeter Nurse" to have bypassed Triage and have the patient go straight to the Resuscitation Room. From the time the patient went from the "Greeter Nurse" to the Resuscitation Room, she had a slight decline, she complained of shortness of breath. Staff #2 also stated "through questions were needed" from the "Greeter Nurse" when she was assessing the patient.

Review of Patient#11's Medical Record revealed on 01/22/15 at 4:17PM the patient presented to the Emergency Department with a chief complaint of swelling of lips and tongue and difficulty speaking after taking medication for tooth pain. The Physician's History and Physical documented difficulty breathing, swelling of face and tongue, difficulty swallowing, shortness of breath and anxiety. Status post ingestion of Chinese antibiotic four (4) hours ago now presenting with swollen tongue, difficulty swallowing and unable to handle secretions. The patient was positive for dyspnea, ill appearing, in severe distress, swollen tongue, a partially occluded throat, drooling, hot-potato voice, swollen tongue and a partially occluded airway. At 4:33PM Epinephrine, Prednisone, Benadryl, and Pepcid were administered as per Physician's Orders. At 4:41PM the patient continued to have difficulty swallowing and Epinephrine was administered as per the Physician's Order. At 5:30PM the patient stated she could breathe easier.