HospitalInspections.org

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


A. ensure there was a sufficient number of RN's to provide emergency services in 1 of 1 Emergency Department.

Refer to A0392 for additional information.



B. ensure nursing staff initiated interventions timely in the patient's care plan which included a physician's recommendation for psych services. Nursing staff failed to follow physician's orders to obtain psych consultation for a patient presenting with psychological symptoms.

C. ensure ED nursing staff obtained thorough psych assessments

D. ensure nursing staff on the nursing unit documented least restrictive interventions prior to administration of psychotropic medications.


Refer to A0396 for additional information.

Based on observation, interview and record review, the facility failed to ensure there was a sufficient number of RN's to provide emergency services in 1 of 1 Emergency Department.

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

Findings include:

During an observation on 09/17/2015, after 11:30 a.m., the registration area, triage area, hallway and rapid medical assessment area were full of patients. Two nurses were observed working the RMA (Rapid Medical assessment) area. A charge nurse was over the entire ED and was caring for 4 patients.

During confidential interviews the following was reported about staffing in the ED:
*They were suppose to have two nurses, but sometimes one nurse works in RMA area. It is difficult to get everything done in RMA.

*Sometimes the RMA area is so full of patients they are directed back to the registration area and in the hallways.

*The charge nurse is over the entire ED, takes patients and serves as secondary trauma nurse.

*Safe harbor had been filed, but nothing was being done about staffing in the ED.

*There has been a nurse staffing problem in the ED since April or May 2014.


During an interview on 09/17/2015, after 11:30 a.m., the ED director (Staff #11) reported a lot of the nurses have left and taken jobs at free standing EDs. Right now they have 5 new nurses in orientation and was still in need of 5 more positions. On an average, the ED sees 137 patients per day. Staff #11 reported they did have a staffing matrix to go by, but her required staffing numbers were as follows daily:

7:00 a.m.-7:00 p.m. shift - 9 RN's;

7:00 p.m.-7:00 a.m. shift - 9 RN's;

11:00 a.m.-3:00 a.m. shift - Peak hours there should be 2 more RN's making a total of 11 nurses during this timeframe.

Staff #11 reported the unit should be staffed as follows in the different areas in the ED:

Triage one nurse;

RMA two nurses;

Room #1 one nurse and was a 4 bed room;

Room #2 and #4 one nurse;

Room #3 one nurse and was a 4 bed room;

Room #5 one nurse and was a 6 bed room. During peak hours two nurses was required;

Room #6 one nurse and was a 4 bed room;

Room #7 was going to have 4 beds after they complete renovations. The rooms would be holding rooms for psych patients;

And they did not staff for Room #8, 9, and 10.


Review of the daily census from 09/07-16 /2015, revealed a range of 115-157 patients per day.

Review of staffing sheets and ED census information revealed the following from 09/07/2015- 09/16/2015, the facility was short of RN's on a daily basis in a range from 1 to 4 nurses throughout the day and night shift.

On 09/07/2015, 09/11//2015, 09/12/2015, 09/14/2015 and 09/16/2015, there were times throughout the 24 hour shifts where there was 6 nurses working in the ED.

On 09/10/2015 there was a timeframe where there was 5 nurses working the ED.

Review of the ED assignment sheet revealed the following shortages in the RMA area:
On 09/08/2015 from 7:00 a.m.-9:00 a.m. there was 1 nurse in RMA.
On 09/09/2015 after 3:00 a.m. there was 1 nurse in RMA.
On 09/10/2015 from 5:00-11:00 a.m. there was 1 nurse in RMA.
On 09/11/2015 after 7:00 p.m. there was 1 nurse in RMA.
On 09/12/2015 after 7:00 p.m. there was 1 nurse in RMA.
On 09/13/2015 after 11:00 p.m. there was 1 nurse in RMA.
On 09/14/2015 after 7:00 p.m. there was 1 nurse in RMA.
On 09/15/2015 after 11:00 p.m. there was 1 nurse in RMA.

Staff #11 confirmed the staffing numbers and that there was a shortage in nurses in the ED.

During an interview on 09/17/2015, after 2:00 p.m., Staff #3 (Chief Nursing Officer) was questioned about what was being done about the staffing problem in the ED. Staff #3 reported they were recruiting and had received several nursing staff from one of their other campuses. The staff from the other campus had been placed on other units, but the ED did not get any of those staff.

Review of a facility policy named "Five-level Triage" dated 01/2013 revealed the following:
"PURPOSE:
To provide guidelines to rapidly assess patients presenting to the Emergency Department and assign initial Triage Categories according to ESI (Emergency Severity Index) Five Level Triage Criteria. Triage is a rapid process that evaluates chief complaint, presenting symptoms, and assigns acuity level according to ESI Five Level Triage standards."
Level 1 (Emergent)
Level 2 (Semi-Emergent)
Level3 (Urgent)
Level 4 (Semi- Urgent)
Level 5 (Non-Urgent)

Review of the facility policy named "Emergency Department Medical Screening Process" revised 01/2013 revealed the following:

2. Rapid Medical Assessment area will be staffed with a Qualified Medical Person and an Emergency Department Staff member.

3. Patients will be seen in the Rapid Medical Assessment area based on Acuity
a. Patients with an Acuity of 3, 4, or 5 should be seen in the RMA to determine the need for treatment and appropriate location of treatment.

b. Patients who have acuity of 1 or 2 will be placed in a treatment room in the Emergency Department, when bed available.

4. Patients who present with an Acuity of 3, 4, or 5 will be seen in RMA by the Qualified Medical Person

a. Determination if an emergency medical condition exists is made at that time.

b. After the determination, the chart is given to nursing personnel.

Based on interview and record review the facility failed to:
A. ensure nursing staff initiated interventions timely in the patient's care plan which included a physician's recommendation for psych services. Nursing staff failed to follow physician's orders to obtain psych consultation for a patient presenting with psychological symptoms.
B. ensure ED nursing staff obtained thorough psych assessments
C. ensure nursing staff on the nursing unit documented least restrictive interventions prior to administration of psychotropic's.
This deficient practice was found on 1 of 1 patients (Patient #1) and had the likelihood to cause harm in all patients.

Findings include:

Review of the clinical record on Patient #1 revealed she was a 63 year old female who presented to the ED on 09/11/2015 at 12:04 p.m., with a diagnosis of Altered mental status. Patient #1 was triaged at 12:27 p.m. and given an Acuity level of 2 (Semi-Emergent).
Review of nursing documentation on 09/11/2015 at 12:27 p,.m. revealed " EMS REPORTS FAMILY WAS WITH PT WHEN SHE STARTED BECOMING UNRESPONSIVE AT 11:30. FAMILY STS THAT PT TOLD THEM SHE WAS NOT FEELING GOOD AROUND 8:00AM. PT OPENS EYES MOANS TO PAINFUL STIMULATION AND NOT FOLLOWING COMMANDS. ON ARRIVAL TO ED PT BROUGHT STRAIGHT TO CT. AFTER TALKING WITH FAMILY. FAMILY STS PT WAS HAVING ANXIETY ATTACK THIS AM AND WAS ABLE TO CALM PT FOR ONLY A SHORT TIME PRIOR TO PT BECOMING UNRESPONSIVE."
There was no documentation of an assessment by nursing in the ED of any past psychological history.
Review of the ED physician's assessment dated 09/11/2015 (no time) revealed Patient #11 was catatonic. One of the diagnoses listed on the assessment was Depression. According to the physician, Patient #1's workup was negative, however she was altered and was being admitted for further evaluation and treatment. The order was to admit to telemetry.
At 8:39 p.m., Patient #1 was transported to the nursing floor.
Review of a nursing assessment dated 09/11/2015 at 9:00 p.m.(over 8 hours after presenting) there was a psychiatric section where there was documentation of Patient #1 having a history of a nervous breakdown and depression. There was also documentation of there being a history of panic disorders.
Review of a physician's order dated 09/11/2015 (not timed) revealed an order for a psych consult. The order was written by the admitting physician.
Review of a neurologist consult dated 09/11/2015 which was dictated at 9:59 p.m. revealed he saw Patient #1 at the request of the admitting physician. The neurologist documented Patient #1 had a "history of pseudoseizures 20 years ago, during which time she was stressed out. She had some problems with her relationship. However, she is now having the same symptoms, described as blank star, unresponsive, and subsequently confused. She continues to be unchanged of her characteristics. Ct scan of the brain did not reveal any acute findings. However, patient's family members described similar symptoms 20 years ago, and she was diagnosed pseudoseizures." .. "At this point, given the stereotypic presentation that she had experienced 20 years ago and the level of stress she is on, and her having an emotional breakdown, current problem is stress-induced seizures. I would not put her on any seizure medications. Consult psychiatry, however, requiring an MRI of the brain and EEG for further evaluation."
Review of a physician assessment dated 09/12/2015 at 8:40 a.m., revealed part of the plan for Patient #1 was "if all workup was negative and neuro clear she could go home. Psych consult in case she is still here next week."
On 09/12/2015 at 1:45 a.m., a telephone order was written for Ativan 1 milligrams by mouth. The order did not specify the reason for the medication. The Ativan was administered at 1:45 a.m. There was no documentation of an assessment to justify the reason for the medication and there was no documentation of interventions attempted prior to administration of the medication.
On 09/12/2015 at 1:30 p.m., Staff #12 documented the following;
"PATIENT FAMILY AT BEDSIDE, PATIENT IS THRASHING HER LEGS AND ARM, TWISTING HER BODY SIDE TO SIDE, FAMILY ASKED SHE HAS ANYTHING ORDER TO CALM HER, EXPLAIN TO FAMILY NO MEDICATION ORDER WILL CALL HER DOCTOR FOR SEDATION ORDER, ALSO EXPRESS DO NOT FEEL LIKE PATIENT IS GETTING THE CARE SHE NEEDS, THAT SHE NEED PSYCHIATRY CARE, EXPLAIN TO FAMILY THAT THERE IS NO PSYCHIATRY PHYSICIAN THAT PRACTICE AT THIS HOSPITAL, CALL PLACED FOR DR. #17 REGARDING SEDATION MEDICATION.
On 09/12/2015 at 1:35 p.m., Lexapro 20 milligrams was administered. There was documentation the family gave her medication.
On 09/12/2015 at 2:45 p.m., the following was documented by Staff #12:
"ORDER RECEIVED FOR 1 MG PO ATIVAN, PATIENT MEDICATED WITH 1 MG PO ATIVAN, HAD EXPLAIN TO DR.(#16) (ON CALL FOR DR#17) THAT PATIENT FAMILY REQUEST SHE BE DISCHARGED SO SHE CAN BE BROUGHT TO (HOSPITAL B), NO ORDERS RECEIVED, PATIENT CONT TO THRASH ARMS AND LEG, THRASHING FROM SIDE TO SIDE. BUT WHEN GIVEN PATIENT HER MEDICATION WOULD STOP THRASHING TO TAKE HER MEDICATION AND DRINK WATER"
There was no documentation of interventions attempted prior to administration of the medication by nursing.
On 09/12/2015 at 3:14 p.m., Staff #12 documented the following:
"PATIENT FAMILY SIGN PATIENT OUT AGAINST MEDICAL ADVISE, PATIENT DISCHARGE AMA, FAMILY PLAN TO BRING PATIENT TO (HOSPITAL B, SO SHE CAN RECEIVE PSCYCHIAT(PSYCHIATRIC) EVALUATION, NURSING SUPERVISOR AND DR (#16) (ON CALL FOR DR (#17) INFORMED, REMOVED FROM HEART MONITOR, SALINE LOCK REMOVED, DISCHARGED AMA"
Review of the record revealed Patient #1 was discharged by her family via car to Hospital B.

Review of another medical record on Patient #1 revealed she presented to Hospital B on 09/12/2015 at 4:07 p.m. with a diagnosis of psychosis.
According to documentation at 4:35 p.m., Patient #1's daughter stated "We were seen at (Hospital A) yesterday they admitted her for obs and wanted to do an EEG this morning and told me that they were waiting on the neurologist to read it but he wouldn't be back until later his evening to make rounds. The nurse then told me she needed a psychiatric evaluation and they don't offer those services at their facility but they could try to get an evaluation Mon. and that (Hospital A) doesn't have a psychiatrist. They told us she would be better to come to (Hospital B) because yall are affiliated with the (Behavior Center C). The nurse called the doctor to try to get him to discharge her but he wouldn't so they basically said it would be better for use to sign her out AMA and bring her here so she could be evaluated."
According to documentation Patient #1 was admitted to Behavior Center C on 09/12/2015 at 11:36 p.m.

During an interview on 09/16/2015 after 1:00 p.m., Staff #7 confirmed the missing information in the chart at Hospital A.
During an interview on 09/16/2015 after 4:30 p.m., Staff #8 confirmed she was the supervisor working the day Patient #1 was discharged. Staff #8 confirmed she was told by Staff #12 after Patient #1 had left AMA. Staff #8 confirmed they had a nurse practitioner who they consulted for psych evals. If she was told while Patient #1 was there she would have went and tried to get the patient to stay because sometimes they could get Behavior Center C to come over to their hospital.
During an interview on 09/17/2015 after 11:00 a.m., Staff #12 confirmed she was the nurse who gave the last dose of Ativan that was charted and discharged Patient #1. Staff #12 confirmed the medication was given because of the patient's behavior and the family wanted her to give the patient something to calm her down. Staff #12 confirmed there was no documentation of the interventions attempted prior to administration of the medication. The family also wanted Patient #1 to have a psych consult. Staff #12 reported she told the family they did not provide psych services. In the future if there was a psych problem with Patient #1 go to the ED at Hospital B. Staff #12 confirmed she did not call the Nurse practitioner for a psych consult. She explained to the family that Hospital B could evaluate Patient #1. Staff #12 reported she called Dr #16 who was on call for Dr #17. Staff #12 reported Dr #16 would not give a transfer order and would not talk to her directly. Messages were passed through his nurse. Staff #12 reported she told Dr#16 if Patient #1 was not transferred the family would sign her out AMA. Staff #12 reported Dr.#16 told her if that's what they are going to do that's what they need to do. Staff #12 confirmed she did not call Hospital B to inform them Patient #1 was coming there.
Review of the undated duties of the facility's "Psychiatric Consultation-Liaison Nurse Practitioner" revealed the following:
Identifies specialized care needs of patients in the emergency department and on the medical floors who are identified as needing mental health assessment or interventions.
Screen patients, as needed, for suicidality and determines appropriate referrals and disposition(such as inpatient or outpatient treatment).
Intervenes with patients who have physician orders for mental health services to assess mental health problems and recommend appropriate clinical interventions up to and including assessment, diagnosis and treatment.
Ensures that care provided is appropriate, effective, and beneficial to the patient.
Facilitates transfer of patients from medical floors to community inpatient and outpatient psychiatry services as appropriate.

Based on interview and record review the facility failed to ensure an in-patient with an emergency medical condition was provided a safe transfer. The facility failed to ensure the nurse practitioner pysch consultant was called to facilitate a transfer of a patient to community inpatient or outpatient psychiatry services as appropriate.
This deficient practice was found on 1 of 1 patients (Patient #1) and had the likelihood to cause harm in all patients.

Findings include:

Review of the clinical record on Patient #1 revealed she was a 63 year old female who presented to the ED on 09/11/2015 at 12:04 p.m., with a diagnosis of Altered mental status. Patient #1 was triaged at 12:27 p.m. and given an Acuity level of 2 (Semi-Emergent).
Review of nursing documentation on 09/11/2015 at 12:27 p,.m. revealed " EMS REPORTS FAMILY WAS WITH PT WHEN SHE STARTED BECOMING UNRESPONSIVE AT 11:30. FAMILY STS THAT PT TOLD THEM SHE WAS NOT FEELING GOOD AROUND 8:00AM. PT OPENS EYES MONES TO PAINFUL STIMULATION AND NOT FOLLOWING COMMANDS. ON ARRIVAL TO ED PT BROUGHT STRAIGHT TO CT. AFTER TALKING WITH FAMILY. FAMILY STS PT WAS HAVING ANXIETY ATTACK THIS AM AND WAS ABLE TO CALM PT FOR ONLY A SHORT TIME PRIOR TO PT BECOMING UNRESPONSIVE."
There was no documentation of an assessment by nursing in the ED of any past psychological history.
Review of the ED physician's assessment dated 09/11/2015 (no time) revealed Patient #11 was catatonic. One of the diagnoses listed on the assessment was Depression. According to the physician, Patient #1's workups was negative, however she was altered and was being admitted for further evaluation and treatment. The order was to admit to telemetry.
At 8:39 p.m., Patient #1 was transported to the nursing floor.
Review a nursing assessment dated 09/11/2015 at 9:00 p.m.(over 8 hours after presenting) there was a psychiatric section where there was documentation of Patient #1 having a history of a nervous breakdown and depression. There was also documentation of there being a history of panic disorders.
Review of a physician's order dated 09/11/2015 (not timed) revealed an order for a psych consult. The order was written by the admitting physician.
Review of a neurologist consult dated 09/11/2015 which was dictated at 9:59 p.m. revealed he saw Patient #1 at the request of the admitting physician. The neurologist documented Patient #1 had a "history of pseudoseizures 20 years ago, during which time she was stressed out. She had some problems with her relationship. However, she is now having the same symptoms, described as blank star, unresponsive, and subsequently confused. She continues to be unchanged of her characteristics. Cat scan of the brain did not reveal any acute findings. However, patient's family members described similar symptoms 20 years ago, and she was diagnosed pseudoseizures." .. "At this point, given the stereotypic presentation that she had experienced 20 years ago and the level of stress she is on, and her having an emotional breakdown, current problem is stress-induced seizures. I would not put her on any seizure medications. Consult psychiatry, however, requiring an MRI of the brain and EEG for further evaluation."
Review of a physician assessment dated 09/12/2015 at 8:40 a.m., revealed part of the plan for Patient #1 was "if all workup was negative and neuro clear she could go home. Psych consult in case she is still here next week."
On 09/12/2015 at 1:45 a.m., a telephone order was written for Ativan 1 milligrams by mouth.
On 09/12/2015 at 1:30 p.m., Staff #12 documented the following;
"PATIENT FAMILY AT BEDSIDE, PATIENT IS THRASHING HER LEGS AND ARM, TWISTING HER BODY SIDE TO SIDE, FAMILY ASKED SHE HAS ANYTHING ORDER TO CALM HER, EXPLAIN TO FAMILY NO MEDICATION ORDER WILL CALL HER DOCTOR FOR SEDATION ORDER, ALSO EXPRESS DO NOT FEEL LIKE PATIENT IS GETTING TO CARE SHE NEEDS, THAT SHE NEED PSYCHIATRY CARE, EXPLAIN TO FAMILY THAT THESE ARE IS NO PSYCHIATRY PHYSICIAN THAT PRACTICE AT THIS HOSPITAL, CALL PLACED FOR DR. #17 REGARDING SEDATION MEDICATION.
On 09/12/2015 at 1:35 p.m., Lexapro 20 milligrams was administered. There was documentation the family gave her medication.
On 09/12/2015 at 2:45 p.m., the following was documented by Staff #12:
"ORDER RECEIVED FOR 1 MG PO ATIVAN, PATIENT MEDICATED WITH 1 MG PO ATIVAN, HAD EXPLAIN TO DR.(#16) (ON CALL FOR DR#17) THAT PATIENT FAMILY REQUEST SHE BE DISCHARGED SO SHE CAN BE BROUGHT TO (HOSPITAL B), NO ORDERS RECEIVED, PATIENT CONT TO THRASH ARMS AND LEG, THRASHING FROM SIDE TO SIDE. BUT WHEN GIVEN PATIENT HER MEDICATION WOULD STOP THRASHING TO TAKE HER MEDICATION AND DRINK WATER"
On 09/12/2015 at 3:14 p.m., Staff #12 documented the following:
"PATIENT FAMILY SIGN PATIENT OUT AGAINST MEDICAL ADVISE, PATIENT DISCHARGE AMA, FAMILY PLAN TO BRING PATIENT TO (HOSPITAL B, SO SHE CAN RECEIVE PSCYCHIAT(PSYCHIATRIC) EVALUATION, NURSING SUPERVISOR AND DR (#16) (ON CALL FOR DR (#17) INFORMED, REMOVED FROM HEART MONITOR, SALINE LOCK REMOVED, DISCHARGED AMA"
Review of the record revealed Patient #1 was discharged by her family via car to Hospital B.

Review of another medical record on Patient #1 revealed she presented to Hospital B on 09/12/2015 at 4:07 p.m. with a diagnosis of psychosis.
According to documentation at 4:35 p.m., Patient #1's daughter stated "We were seen at (Hospital A) yesterday they admitted her for obs and wanted to do an EEG this morning and told me that they were waiting on the neurologist to read it but he wouldn't be back until later his evening to make rounds. The nurse then told me she needed a psychiatric evaluation and they don't offer those services at their facility but they could try to get an evaluation Mon. and that (Hospital A) doesn't have a psychiatrist. They told us she would be better to come to (Hospital B) because yall are affiliated with the (Behavior Center C). The nurse called the doctor to try to get him to discharge her but he wouldn't so they basically said it would be better for use to sign her out AMA and bring her here so she could be evaluated."
According to documentation Patient #1 was admitted to Behavior Center C on 09/12/2015 at 11:36 p.m.

During an interview on 09/16/2015 after 1:00 p.m., Staff #7 confirmed the missing information in the chart at Hospital A.
During an interview on 09/16/2015 after 4:30 p.m., Staff #8 confirmed she was the supervisor working the day Patient #1 was discharged. Staff #8 confirmed she was told by Staff #12 after Patient #1 had left AMA. Staff #8 confirmed they had a nurse practitioner who they consulted for psych evals. If she was told while Patent #1 was there she would have went and tried to get the patient to stay because sometimes they could get Behavior Center C to come over to their hospital.
During an interview on 09/17/2015 after 11:00 a.m., Staff #12 confirmed she was the nurse who gave the last dose of Ativan that was charted and discharged Patient #1. Staff #12 confirmed the medication was given because of the patient's behavior and the family wanted her to give the patient something to calm her down. Staff #12 confirmed there was no documentation of the interventions attempted prior to administration of the medication. The family also wanted Patient #1 to have a psych consult. Staff #12 reported she told the family they did not provide psych services. In the future if there was a psych problem with Patient #1 go to the ED at Hospital B. Staff #12 confirmed she did not call the Nurse practitioner for a psych consult. She explained to the family that Hospital B could evaluate Patient #1. Staff #12 reported she called Dr #16 who was on call for Dr #17. Staff #12 reported Dr #16 would not give a transfer order and would not talk to her directly. Messages were passed through his nurse. Staff #12 reported she told Dr#16 if Patient #1 was not transferred the family would sign her out AMA. Staff #12 reported Dr.#16 told her if that's what they are going to do that's what they need to do. Staff #12 confirmed she did not call Hospital B to inform them Patient #1 was coming there.
Review of the undated duties of the facility's "Psychiatric Consultation-Liaison Nurse Practitioner" revealed the following:
Identifies specialized care needs of patients in the emergency department and on the medical floors who are identified as needing mental health assessment or interventions
Screen patients, as needed, for suicidality and determines appropriate referrals and disposition(such as inpatient or outpatient treatment).
Intervenes with patients who have physician orders for mental health services to assess mental health problems and recommend appropriate clinical interventions up to and including assessment, diagnosis and treatment.
Ensures that care provided is appropriate, effective, and beneficial to the patient.
Facilitates transfer of patients from medical floors to community inpatient and outpatient psychiatry services as appropriate.

Review of the facility's"Patient Rights & Responsibilites" revealed the following:
Acess to Care. You have the right, within the hospital's capacity, policies, mission statement and applicable law, to a reasonable and impartial response to your request for treatment or services that are available and medically indicated.

Transfer and Continuity of Care. You have the right not to be transferred to another facility or organization until you have received a complete explanation of the need of the transfer and of the alternatives to such a transfer. Any transfer of patients must be acceptable to the other facilty or organization. You have the right to be informed of continuing health care requirements that your physician feels you may need after you leave the hospital.

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


A. ensure ED nursing staff obtained a thorough psych assessments on 1of 1 patients (Patient #1). Patient #1 did not receive a thorough psych assessment from nursing until over 8 hours after presenting to the ED.

Review of the clinical record on Patient #1 revealed she was a 63 year old female who presented to the ED on 09/11/2015 at 12:04 p.m., with a diagnosis of Altered mental status. Patient #1 was triaged at 12:27 p.m. and given and Acuity level of 2 (Semi-Emergent).
Review of nursing documentation on 09/11/2015 at 12:27 p,.m. revealed " EMS REPORTS FAMILY WAS WITH PT WHEN SHE STARTED BECOMING UNRESPONSIVE AT 11:30. FAMILY STS THAT PT TOLD THEM SHE WAS NOT FEELING GOOD AROUND 8:00AM. PT OPENS EYES MONES TO PAINFUL STIMULATION AND NOT FOLLOWING COMMANDS. ON ARRIVAL TO ED PT BROUGHT STRAIGHT TO CT. AFTER TALKING WITH FAMILY. FAMILY STS PT WAS HAVING ANXIETY ATTACK THIS AM AND WAS ABLE TO CALM PT FOR ONLY A SHORT TIME PRIOR TO PT BECOMING UNRESPONSIVE."
There was no documentation of an assessment by nursing in the ED of any past psychological history.
Review of the physician's assessment dated 09/11/2015 (no time) revealed Patient #11 was catatonic. One of the diagnoses listed on the assessment was Depression. According to the physician Patient #1's workup was negative, however she was altered and was being admitted for further evaluation and treatment. The order was to admit to telemetry. There was no time on the orders.
At 8:39 p.m., Patient #1 was transported to the nursing floor.
Review a nursing assessment on 09/11/2015 at 9:00 p.m.(over 8 hours after presenting) underneath the psychiatric section there was documentation of Patient #1 having a history of a nervous breakdown and depression. There was also documentation of there being a history of panic disorders.
Review of a physician's order dated 09/11/2015 (not timed) revealed an order for a psych consult. The order was written by the admitting physician.


B. ensure there was a sufficient number of RN's to provide emergency services in 1 of 1 Emergency Department.


During an observation on 09/17/2015 after 11:30 a.m., the registration area, triage area, hallway and rapid medical assessment area were full of patients. Two nurses were observed working the the RMA (Rapid Medical assessment) area. A charge nurse was over the entire ED and was caring for 4 patients.

During confidential interviews the following was reported about staffing in the ED:
*They were suppose to have two nurses, but sometimes one nurse works in RMA area. It is difficult to get everything done in RMA.
*Sometimes the RMA area is so full patients they are directed back to the registration area and in the hallways.
*The charge nurse is over the entire ED, takes patients and serves as secondary trauma nurse.
*Safe harbor had been filed, but nothing was being done about staffing in the ED.
*There has been a nurse staffing problem in the ED since April or May 2014.

During an interview on 09/17/2015 after 11:30 a.m., the ED director (Staff #11) reported a lot of the nurses have left and taken jobs at free standing EDs. Right now they have 5 new nurses in orientation and was still in need of 5 more positions. On an average the ED sees 137 patients per day. Staff #11 reported they did have a staffing matrix to go by, but her required staffing numbers were as follows daily:
7:00 a.m.-7:00 p.m. shift - 9 RN's;
7:00 p.m.-7:00 a.m. shift - 9 RN's;
11:00 a.m.-3:00 a.m. shift - Peak hours there should be 2 more RN's making a total of 11 nurses during this timeframe.
Staff #11 reported the unit should be staffed as follows in the different areas in the ED:
Triage one nurse;
RMA two nurses;
Room #1 one nurse and was a 4 bed room;
Room #2 and #4 one nurse;
Room #3 one nurse and was a 4 bed room;
Room #5 one nurse and was a 6 bed room. During peak hours two nurses was required;
Room #6 one nurse and was a 4 bed room;
Room #7 was going to have 4 beds after they complete renovations. The rooms would be holding rooms for psych patients;
And they did not staff for Room #8, 9, and 10.

Review of the daily census from 09/07-16 /2015 revealed a range of 115-157 patients per day.

Review of staffing sheets and ED census information revealed the following from 09/07/2015- 09/16/2015 the facility was short of RN's on a daily basis in a range from 1 to 4 nurses throughout the day and night shift.
On 09/07/2015, 09/11//2015, 09/12/2015, 09/14/2015 and 09/16/2015 there were times throughout the 24 hour shifts where there was 6 nurses working in the ED.
On 09/10/2015 there was a timeframe where there was 5 nurses working the ED.

Review of the ED assignment sheet revealed the following shortages in the RMA area:
On 09/08/2015 from 7:00 a.m.-9:00 a.m. there was 1 nurse in RMA.
On 09/09/2015 after 3:00 a.m. there was 1 nurse in RMA.
On 09/10/2015 from 5:00-11:00 a.m. there was 1 nurse in RMA.
On 09/11/2015 after 7:00 p.m. there was 1 nurse in RMA.
On 09/12/2015 after 7:00 p.m. there was 1 nurse in RMA.
On 09/13/2015 after 11:00 p.m. there was 1 nurse in RMA.
On 09/14/2015 after 7:00 p.m. there was 1 nurse in RMA.
On 09/15/2015 after 11:00 p.m. there was 1 nurse in RMA.
Staff #11 confirmed the staffing numbers and that there was a shortage in nurses in the ED.
During an interview on 09/17/2015 after 2:00 p.m., Staff #3 (Chief Nursing Officer) was questioned about what was being done about the staffing problem in the ED. Staff #3 reported they were recruiting and had received several nursing staff from one of their other campuses. The staff from the other campus had been placed on other units, but the ED did not get any of those staff.

Review of a facility policy named "Five-level Triage" dated 01/2013 revealed the following:
"PURPOSE:
To provide guidelines to rapidly assess patients presenting to the Emergency Department and assign initial Triage Categories according to ESI (Emergency Severity Index) Five Level Triage Criteria. Triage is a rapid process that evaluates chief complaint, presenting symptoms, and assigns acuity level according to ESI Five Level Triage standards."
Level 1 (Emergent)
Level 2 (Semi-Emergent)
Level3 (Urgent)
Level 4 (Semi- Urgent)
Level 5 (Non-Urgent)

Review of the facility policy named "Emergency Department Medical Screening Process" revised 01/2013 revealed the following:
2. Rapid Medical Assessment area will be staffed with a Qualified Medical Person and an Emergency Department Staff member.
3. Patients will be seen in the Rapid Medical Assessment area based on Acuity
a. Patients with an Acuity of 3, 4, or 5 should be seen in the RMA to determine the need for treatment and appropriate location of treatment.
b. Patients who have acuity of 1 or 2 will be placed in a treatment room in the Emergency Department, when bed available.
4. Patients who present with an Acuity of 3, 4, or 5 will be seen in RMA by the Qualified Medical Person
a. Determination if an emergency medical condition exists is made at that time.
b. After the determination, the chart is given to nursing personnel.

Based on record review and interview the facility failed to complete 143 of 421 Method of Transfer (MOT) forms for patients received to the facility from other hospitals over a three months time span July,August and part of September of 2015.

On 9/17/2015 at 9:00 a.m. in the conference room MOT's were reviewed and of the 421 MOT's reviewed 143 were identified as incomplete. The 143 incomplete MOT's did not have the information of the receiving hospital completed. The incomplete MOT's represented patients who required a higher level of care and were transferred from 14 separate hospitals. This was confirmed by staff #1.

Further review revealed three (3) of the 143 incomplete MOT's were signed by a physician but no other information was found on the form. The signatures did not match indicating two (2) separate physician's signed MOT's without completion by a nurse.

Further review identified 20 of the 143 incomplete MOT's had neither the sending or the receiving hospital identified. There was no way to determine from the MOT where the patient was transferred from or to.