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Based on records reviewed and interviews the Hospital failed to ensure the Quality Assessment and Performance Improvement (QAPI) Program reflected the complexity of the Hospital's organization and services; involved all Hospital departments and focused on adverse patient event prevention.

Findings included:

The Hospital QAPI Program failed to ensure identification of opportunities for improvement regarding: 1.) thorough investigations regarding oxygen tubing disconnections for two patients receiving supplemental oxygen, 2.) immediate availability of intravenous pumps in the Emergency Department, as a high-risk, high-volume area, and 3.) Hospital departmental response to Code Help's called to the Emergency Department.

Refer to TAG: A-0283.

Hospital's Executives failed to assume full accountability for ensuring Quality Assessment and Performance Improvement (QAPI) efforts addressed improved quality of care and patient safety with a QAPI process that improved Emergency Department Nursing issues related to staffing.

Refer to TAG: A-0309.

Based on records reviewed and interviews, although the Hospital collected data, the Hospital Quality Assessment and Performance Improvement Program failed for a total of six patients; three sampled patients (Patients #2, #9 & #10) and three unsampled patients (Unsampled Patients #1, #2, & #3) to ensure identification of opportunities for improvement regarding:

1.) thorough investigations regarding oxygen tubing disconnections for patients receiving supplemental oxygen (Patients #2 & #9),

2.) immediate availability of intravenous pumps in the Emergency Department, as high-risk, high-volume area (Patient #10 & Unsampled Patients #1, 2, 3.),

3.) Hospital departmental response to Code HELPs called to the Emergency Department.

and after implementing actions, measured success, and track performance to ensure that improvements were sustained.

Findings included:

Quality and Patient Safety Plan, dated 11/2021 and approved by Good Samaritan Medical Center, indicated Steward Health Care System had adopted principles for quality and patent safety to guide its efforts to improve organizational performance that in turn would provide the safest possible care and optimize the patient care experience for all its patients and families.

1.) Regarding Oxygen Administration of Patients #2 & #9:

Regarding Patient #2:

The Hospital Report dated, 6/16/2022, indicated a Complainant alleged the Hospital was not administering supplemental oxygen to an oxygen-dependent patient (Patient #2) upon return from a hemodialysis treatment.

During the interview, at 8:00 A.M. on 11/9/2022, Risk Manager #1 said Patient #2 had many co-morbidities (simultaneous presence of two or more diseases or medical conditions) including End State Renal Disease (ESRD, end stage kidney disease), heart failure, and Chronic Obstructive Pulmonary Disease (COPD). Risk Manager #1 said the Hospital conducted an investigation regarding a complaint submitted to the Hospital of Patient #2 not receiving supplemental oxygen on return from a dialysis treatment; a family member noticed the oxygen tubing was disconnected, a nurse immediately connected the oxygen tubing, and it remained unknown how long the Patient was without supplemental oxygen.

During the interview, at 12:00 P.M. on 11/10/2022, Risk Manager #1 said it remained unknown how the oxygen tubing became disconnected.

The Hospital provided no documentation regarding investigation how an oxygen dependent Patient was without supplemental oxygen.

Regarding Patient #9:

The Hospital Report, dated 12/15/2022, indicated Patient #9 arrived in a Medical Surgical Unit with a non-rebreather (an oxygen mask to provide a high-level of oxygen) not connected to oxygen.

The Hospital Follow-Up Report, dated 11/9/2022, indicated no follow-up information regarding Patient #9's arrival from the ED to the Medical Surgical Unit with a non-rebreather not connected to oxygen.

The Hospital provided no follow-up actions to the Hospital report, dated 11/9/2022, regarding Patient #9.

2.) Regarding Availability of Intravenous Pumps and working equipment, Patient #10 and Unsampled Patients #1, #2, & #3.

Regarding Patient #10:

During the interview, at 9:30 on 11/9/2022, Registered Nurse (RN) #1 said the Emergency Department had three intravenous pumps, equipment was not working, for example vital sign equipment, two old pumps were delivered to the ED however the Hospital had no intravenous tubing for those two pumps.

The Hospital Report, dated 9/27/2022, indicated Patient #10, with new seizure (activity and brain bleed, no (intravenous) pumps were available in the Patient care room to provide immediate medication drip (constant medication infusion) requiring titration (dose adjustments) secondary to elevated blood pressures.

The Emergency Department Record, dated 9/27/2022 indicated at 8:47 A.M. an ED Physician documented Patient #10 presented to the ED via ambulance after having a witnessed seizure fall, a Computerized Tomography (CT) showed Patient #10 had multiple areas on intraparenchymal hemorrhage within the right frontal lobe with associated vasogenic edema causing subfalcine herniation (serious brain bleed) and Patient #10 was transported via helicopter to a Neurologic (brain) Intensive Care Unit.

The Hospital Follow-Up Report, dated 11/9/2022, indicated we (undefined) were present when the nurse was looking for the pump, Patient #10 did have one at the present time however was going to need an additional (intravenous pump), an order (undefined) was placed in the hob (undefined), and transport brought one (pump) within 5-10 minutes. Senior Leadership Team (STL) and transport manager notified, multiple pumps brought to the ED before Patient #10 left via Med Flight (undefined as ambulance or helicopter transport, to a higher level of care Hospital).

Regarding equipment availability:

ED RN #1 said that Unsampled Patient #1 presented to their ED as a trauma patient from a gun-shot wound, and the ED did not have stocked an appropriate sized chest tube equipment (to evacuate a patient's chest of air or blood), appropriate intravenous catheter (triple lumen central catheter, used to administer fluid and medication resuscitation) or enough intravenous pumps to administer multiple blood pressure medications.

During the interview at, 3:00 P.M. on 11/10/2022, ED RN #3 said regarding equipment, there were not enough: tables (over-bed) for patients to eat, stretchers to care for patients, and intravenous pumps and on a daily basis I have to walk around and find one to administer drips (intravenous medications that require a constant infusion of the medication).

During the interview, at 11:30 A.M. on 11/16/2022, ED RN #2 said ED RN #3 did not have enough intravenous pumps for a patient that:

- had a head bleed from a fall (Unsampled Patient #2), and that the patient needed a fentanyl drip (narcotic, anesthetic medication administered as a constant intravenous drip) and a propofol drip (anesthetic medication administered as a constant intravenous drip) and could not get enough pumps,

-was in ventricular fibrillation (cardiac) arrest (Unsampled Patient #3) to administer intravenous Amiodarone [treats life-threatening ventricular (heart) rhythm problems (arrhythmias)], levophed (treats low blood pressure) nor propofol (medications that required a constant intravenous administration), and

stretchers were broken and would not recline to a flat position to administer cardiac compressions.

3.) Regarding response to Code Help:

The Hospital policy titled Code HELP, dated 11/23/2021, indicated a Code HELP was initiated when the ED was unable to accept any new patients or was unable to care for exiting patients because the acuity impeded provision of safe patient care. Code HELP was a hospital wide response and mobilization of resources to improve patient flow through the ED, enhancing safety, quality and the patient experience. The Code HELP policy indicated hospital wide response included representation from Nursing, ED Nursing and ED Physician; Environmental, Laboratory, Radiology, and Transport Services; and Case Management. The Code HELP policy did not indicate Material Management services were required to respond to a Code H to supply needed supplies and equipment.

DOC/Code Help Tracking Report, dated 6/2022 through 10/2022, indicated a theme of non-attendance. The Code HELP policy did not indicate Material Management services were required to respond to a Code H to supply needed supplies and equipment.

Unsafe Staffing Sheets for ED, dated 7/2022, 8/2022, 9/2022, & 10/2022, indicated fifteen Unsafe Staffing Sheets for the ED with a theme of non-attendance at Code Helps.

The Hospital provided no QAPI activities to improve Hospital departmental response to an ED Code Help consistent with Hospital policy. The Hospital provided no QAPI activity to evaluate the participation of Material Management services were required to respond to a Code Help to supply needed supplies and equipment.

Based on records reviewed and interviews the Hospital's Executives failed for two sampled patients (Patients #6 & #7) to ensure they assumed full accountability that ensured Quality Assessment and Performance Improvement (QAPI) efforts addressed improved quality of care and patient safety with a QAPI process that improved Emergency Department Nursing issues related to staffing.

Findings included:

Quality and Patient Safety Plan [(QAPI) Plan], dated 11/2021 and approved by Good Samaritan Medical Center, indicated Steward Health Care System had adopted principles for quality and patent safety. The QAPI Plan indicated Safety Risk Assessment was a multi-tiered process where staff members closest to patients (for example: nursing staff) identified potential and actual safety risks to patients. The QAPI Plan indicated Hospital leadership, teams and staff engaged in continuous and robust performance improvement activities, with aim of providing care that was safe, effective, and timely.

Regarding Patients #6 and #7:

The Hospital Report, dated 8/12/2022, indicated Patient #6 waited in the Emergency Department (ED) waiting room for more than 14 hours, following a Triage assessment ESI of 2 until brought to a room for treatment, due to low staffing on the night shift.

The Hospital policy titled Emergency Department Nursing Triage, dated, 4/5/2022, indicated patients with an ESI of 2 required evaluation and treatment within minutes.

Refer to TAG: A-385.

The Hospital Report dated 10/8/2022, indicated Patient #7 was left in the ED waiting room for 17 hours with stroke symptoms, loss of vision in one eye and a history of strokes.

The Medical Record of Patient #7, indicated no RN documentation from 1:13 P.M. on 10/7/2022 (the time of Triage) through 10/8/2022 at 8:03 A.M. (approximately 17 hours), to ensure an RN met the nursing care needs for this elderly ED patient with a faster than normal heartbeat, referred for evaluation of a likely Transient Ischemic Attack (TIA, precursor of a stroke).

Refer to TAG: A-385.

During the interview, at 1:30 P.M. on 11/6/2022, the Emergency Department (ED) Nurse Director said that not all the issues in the ED were (nurse) staffing. The ED Nurse Director said the ED was (nurse) staffed to the grid (staffing plan) almost every day except for call outs (nursing staff sick calls). The ED Nurse Director said she was working on a permanent Charge Nurse position and pairing the Triage Nurse with a Registration Clerk procedure. The ED Nurse Director said nursing staff completed Unsafe Staffing Reports, the Hospital had a process to meet with the nurses' labor union weekly, who drove (ran) the meeting, and approved policies and procedures; which delayed action plan implementation.

Unsafe Staffing Sheets for ED, dated 7/2022, 8/2022, 9/2022, & 10/2022, indicated fifteen Unsafe Staffing Sheets for the ED submitted by six different RNs with a theme of non-attendance at Code Helps.

The Hospital policy titled Code HELP, dated 11/23/2021, indicated a Code HELP indicated hospital wide response.

During the interview, at 4:00 P.M. on 11/8/ 2022, the Chief Executive Officer (CEO) said the ED nursing staff had staged callouts (planned sick calls). The CEO said money was not an issue, not enough staff (labor shortage) was the issue.

During the interview, at 11:A.M. on 11/9/2022, the Vice-Chair of the Emergency Department said Registered Nurses were appropriately staffed, staffed at 100% or over staffed, however there were a lot of call outs (sick calls), insane absenteeism, and this was stressful on the Emergency Department.

The Hospital provided no effective plan to resolve the Emergency Departments nursing staffs', perceived or invalid, staffing issues.

Based on records reviewed and interviews the Hospital failed to ensure an organized nursing service to meet the needs of patients.

Findings included:

The Hospital failed for six patients to ensure a well-organized service including numbers of nursing personnel and staff necessary to provide nursing care for all areas of the Hospital.

Refer to TAG: A-0386.

The Hospital Emergency Department Nursing Service failed to ensure a Registered Nurse (RN) supervised and evaluated the nursing care needs for each Emergency Department (ED) patient including the waiting room.

Refer to TAG: A-0395.

Based on records reviewed and interviews the Hospital failed for a total of six patients; four sampled patients (Patients #2, #6, #7, #9) and two unsampled patients & Unsampled Patient #1 & #4) to ensure a well-organized service including numbers of nursing personnel and staff necessary to provide nursing care for all areas of the Hospital.

Findings included:

1.) The Hospital Report dated, 6/16/2022, indicated a Complainant alleged the Hospital was not administering supplemental oxygen to an oxygen-dependent patient (Patient #2) upon return from a hemodialysis treatment.

During the interview, at 8:00 A.M. on 11/9/2022, Risk Manager #1 said it remained unknown how the oxygen tubing became disconnected.

2.) The Hospital Report, dated 8/12/2022, indicated Patient #6 waited in the Emergency Department (ED) waiting room for more than 14 hours, following a Triage assessment ESI of 2 until brought to a room for treatment, due to low staffing on the night shift.

The Hospital policy titled Emergency Department Nursing Triage, dated, 4/5/2022, indicated patients with an ESI of 2 required evaluation and treatment within minutes.

Refer to TAG: A-395.

3.) The Hospital Report dated 10/8/2022, indicated Patient #7 was left in the ED waiting room for 17 hours with stroke symptoms, loss of vision in one eye and a history of strokes.

The Medical Record of Patient #7, indicated no RN documentation from 1:13 P.M. on 10/7/2022 (the time of Triage) through 10/8/2022 at 8:03 A.M. (approximately 17 hours), to ensure an RN met the nursing care needs for this elderly ED patient with a faster than normal heartbeat, referred for evaluation of a likely Transient Ischemic Attack (TIA, precursor of a stroke).

Refer to TAG: A-395.

4.) The Hospital Follow-Up Report, dated 11/9/2022, indicated Patient #9's arrival from the ED to the Medical Surgical Unit with a non-rebreather (an oxygen mask to provide a high-level of oxygen) not connected to oxygen.

5.) During the interview, at 11:30 A.M. on 11/16/2022, ED RN #3 said a 2-year-old child (Unsampled Patient #4), presented to the ED, waited in the waiting room for five hours before being brought back to the ED and transferred to a Pediatric Hospital for new-onset diabetes.

During the interview, at 9:30 A.M. on 11/9/2022, Registered Nurse (RN) #1 said there was no continuity in Nurse Managers, one Nurse Manager was fired because the Nurse Manager advocated for patients (patient safety) and not Steward (the business, that is the Corporation) who did not allow adequate (nurse) staffing.

ED RN #1 said:

-nurses were caring for up to seven patients, there were patients without a nurse caring for patients. RN #1 said she did not know the details.

-there was no ancillary (staff) help. ED RN #1 said the ED provided horrible care and ED RN #1 did not know of any patient(s) that died regarding the horrible care.

-an Intensive Care Unit (ICU) level of care patient was cared for in the ED because there were no beds in the ICU, the patient required BiPAP (Bilevel Positive Airway Pressure, an advanced respiratory device) and antibiotics. ED RN #1 said there were staffing limits in the ICU and a four to five patient to nurse staffing limit on the medical surgical units and a greater than five patients to one nurse staffing assignment violated the (labor union) contract.

-a trauma patient (Unsampled Patient #1) with a gun-shot wound was arriving and there was no place to put the patient. There was no ED tech to assist, the Surgeon had to do cardiopulmonary resuscitation, could not use the rapid infuser to administer blood because there was no nurse to administer the blood, equipment was not available, documentation was lacking (no one to document), no one to administer and manage multiple life-saving constant infusion medications. ED RN #1 said the patient went to the ICU. ED RN #1 said the other ten patients assigned to the two RN's caring for the trauma patient had no RN for approximately one hour.

-beds were assigned at 2:30 P.M. and 6:30 A.M. when patients were accepted to medical surgical units.

-there was not enough staff to cover meal breaks, eating at the desk was not allowed, staff had to complete a form if they missed a meal break and this was driven by corporate (Steward, the business).

-a patient that was a friend of one of the Hospital's physicians was "bumped to the head of the class" (that is, cared for before other patients) when the ED had patients with ESI's of 2's (required evaluation and treatment within minutes) in the waiting room for twenty hours, a patient (Patient #7) with loss of vision in one eye and another patient with rapid atrial fibrillation (afib, abnormal heart beat).

During the interview, at 11:A.M. on 11/9/2022, the Vice-Chair said he reviewed the case and this was an elderly patient with atrial fibrillation, he (the Vice-Chair) arranged with the Charge Nurse to see (care for) the patient when you can, the patient had an ESI of 2 and the care was appropriate.

ED RN #1 said (he/she, we) have been screaming from the roof top for three years.

During the interview, at 3:00 P.M. on 11/10/2022, ED RN #2 said things were getting worse, (we) do not hear how the Hospital was managing capacity issues, the Hospital needs to build and improve staffing, when there was a trauma patient "it's you", there were five day wait times for admissions, patients leave without being seen, the patient in room #12 had been without a nurse for one hour and this was not an uncommon occurrence, patients in the waiting room on oxygen (delivered by a tank), an RN manages the oxygen tank not a Respiratory Therapist,

During the interview, the Surveyor observed in the ED hallways: a patient having blood drawn, a patients abdomen, visitors, MD in conversation with a patient and family, a patient urinal with urine, on a bedside table; and patients in underwear.

During the interview, at approximately 2:00 P.M. on 11/15/2022. RN #3 said only housekeeping responded to Code Helps, psychiatric patients were eloping, (RN #3 did know the details), as Corporate told the Hospital to decrease Security staffing, a Nurse Manager of forty years was fired and things fell apart, the Chief Nursing Officer was fired out of the blue, the Hospital had empty solutions, travel nurses were orienting new staff, the Triage Nurse was expected to monitor patients in the waiting room, take vital signs, and this was impossible to do.

During the interview, at 11:30 A.M. on 11/16/2022, RN #3 said she triaged one-hundred patients in one shift.

The Policy titled: Patient Assessment, Reassessment and Documentation of Care in the Emergency Department, dated 4/5/2022, indicated reassessment of patients in the waiting room was the responsibility of the Triage Nurse. Refer to TAG: A-395.

During the interview, at 11:00 A.M. on 11/17/2022, RN #3 said a patient waited in the waiting room for seven-teen hours without food or fluids.

The Hospital provided no documentation to support that the Hospital had adequate numbers of nursing personnel and staff necessary to provide nursing care for all areas of the Hospital.

Based on records reviewed and interviews, although increased Emergency Department (ED) visit volume has resulted in ED crowding and increased wait times for minor and sometimes serious problems (https://pubmed.ncbi.nlm.nih.gov/23101886/), the Hospital Emergency Department Nursing Service failed for a total of three patients; two sampled patients (Patients #6 & #7) and one unnsampled patient (Unsampled Patient #4) to ensure a Registered Nurse (RN) supervised and evaluated the nursing care needs for each Emergency Department (ED) patient including the waiting room.

Findings included:

The Policy titled: Patient Assessment, Reassessment and Documentation of Care in the Emergency Department, dated 4/5/2022, indicated:

1.) Vital signs were repeated when abnormal, clinically indicated, and within one hour prior to discharge, admission, or transfer for patients with an ESI of 1, 2, or 3. The minimum frequency of vital signs for active (undefined) ED patients was every 4 hours and for ED boarder patients was every shift.

2.) Ongoing assessment of symptoms and response to treatment as clinically indicated.

3.) Reassessment of patients in the waiting room is the responsibility of the Triage nurse.

The Patient Assessment, Reassessment and Documentation of Care in the Emergency Department policy indicated no individualized patient reassessment and documentation of care regarding pediatric patients, or patients requiring supplemental oxygen therapy.

Regarding Patient #6:

The Hospital Report, dated 8/12/2022, indicated Patient #6 waited in the ED waiting room for more than 14 hours, following a Triage assessment ESI of 2 until brought to a room for treatment, due to low staffing on the night shift.

The Hospital policy titled Emergency Department Nursing Triage, dated, 4/5/2022, indicated patients were triaged into one of the five Emergency Severity Index (ESI) levels:

-Level 1: Patients who require immediate evaluation and treatment with the use of many resources.

-Level 2: Patients who require evaluation and treatment within minutes requiring multiple resources.

-Level 3: Stable patients who could wait up to two hours (120 minutes) for evaluation and treatment requiring multiple diagnostic and therapeutic resources.

-Level 4: Stable patients who could wait for evaluation and treatment requiring one therapeutic diagnostic resource.

-Level 5: Stable patients who could wait for evaluation and treatment and require minimal or no resources.

If a patient has been assessed as ESI level 1 or 2, the patient was brought to the ED treatment area expeditiously and an ED attending (physician) was notified.

Patient #6's Medical Record indicated Patient #6 at:

-5:03 P.M. on 8/12/2022, registered in the ED,

-5:52 P.M. on 8/12/2022, indicated an RN Triaged Patient #6, Patient #6 suffered a Cerebral Vascular Accident (CVA, stroke) in April, now reported weight loss, weakness, decreased mobility and inability to ambulate; a fast heartbeat of 115 beats per minute, an oxygen saturation of 97 (normal) in room air and an ESI of 2.

-5:52 P.M. on 8/12/2022, a Rapid Medical Examination was conducted by a Physician Assistant (non-physician provider and inconsistent with Hospital Triage policy), diagnostic tests were ordered and Patient #6 returned to the waiting room. The Rapid Medical Examination was signed by a Physician Provider at 12:51 A.M. on 8/24/2022.

-5:54 P.M. on 8/12/2022, an Chest X-Ray was done and at 5:57 an Electrocardiogram showed sinus tachycardia (an irregular heartbeat with faster than normal heartbeat).

-7:36 P.M. on 8/12/2022, the Charge RN was unable to assign an available room.

-7:38 A.M. on 8/13/2022, a Physician Provider provided Patient #6's history & physical examination and medical orders. Medical Decision Making included that Patient #6's Troponin T high sensitivity of 15 (possible indication of heart muscle damage, normal 0 and 0.04) however the electrocardiogram was nonischemic (not related to heart disease); with urinalysis suggestive of a urinary tract infection (UTI).

-8:07 A.M. on 8/13/2022 an RN documented the Patient entered the RN's care after waiting in the waiting room for 14 hours and a heartbeat of 112 beats per minute.

The Medical Record of Patient #6, indicated no RN documentation from 5:52 P.M. on 8/12/2022 (the time of Triage) through 7:45 A.M. on 8/13/2022 when an RN collected a urine sample / 7:53 A.M. on 8/13/2022, when an RN performed a nursing assessment (approximately 14 hours), to ensure an RN supervised and evaluated the nursing care needs for this elderly ED patient with a faster than normal heartbeat.

-9:12 A.M. on 8/13/2022, Patient #6 received an intravenous antibiotic.

-5:10 P.M. on 8/13/2020, Patient #6 was admitted as an inpatient for generalized weakness, a urinary tract infection, low magnesium and low potassium blood levels.

The Hospital provided no follow-up actions to the Hospital report, dated 8/12/2022.

Regarding Patient #7:

The Hospital Report dated 10/8/2022, indicated Patient #7 was left in the ED waiting room for 17 hours with stroke symptoms, loss of vision in one eye and a history of strokes.

The Hospital Follow-Up Report, dated 11/9/2022, regarding Patient #7 Hospital Report 10/8/2022, indicated Patient #7's vision loss was 2 days prior and was improving, a Computerized Tomography (CT) was negative and Patient #7 was without acute stroke symptoms on arrival. The Follow-Up Report indicated no follow-up documentation regarding Patient #7's 17 hour wait in the ED waiting room, without an RN re-evaluation for ED nursing care needs.

Patient #7's Medical Record indicated Patient #7 at:

-12:59 P.M. on 10/7/2022 arrived at the ED,

-1:13 P.M. on 10/7/2022 was Triaged, two days ago the Patient had painless loss of vision in the left eye which had improved some since and now vision was haze. Patient #7 was seen today by an eye specialist who recommended follow-up for likely Transient Ischemic Attack (TIA, mini stroke caused by temporary disruption in blood supply to part of the brain).

-1:32 P.M. on 10/7/2022 was seen by an ED Nurse Practitioner (non-physician provider and inconsistent with Hospital Triage policy), indicated Patient #7 had a known history of a Myocardial Infarction (MI, heart attack) and sent to the ED by ophthalmology for vision loss and sent to the ED to rule out a TIA and Rapid Stroke Scale was zero (normal).

-8:03 A.M. on 10/8/2022, Patient #7 was re-evaluated in Triage for complaint of a headache, vital signs were performed with a high heartbeat of 101 beats per minute.

The Medical Record of Patient #7, indicated no RN documentation from 1:13 P.M. on 10/7/2022 (the time of Triage) through 10/8/2022 at 8:03 A.M. (approximately 17 hours), to ensure an RN supervised and evaluated the nursing care needs for this elderly ED patient with a faster than normal heartbeat, referred for evaluation of a likely TIA.

-9:26 A.M. on 10/8/2022, a Physician documented Patient #7's Medical Screening Examination with a plan to admit Patient #7 to the Hospital for further workup and evaluation for possible TIA.

-6:00 P.M. on 10/8/2022 was admitted to the Hospital.

-4:36 P.M. on 10/11/2022 was discharged to home.

Regarding Unsampled Patient #4:

During the interview, at 11:30 A.M. on 11/16/2022, RN #3 said a 2-year-old child (Unsampled Patient #4), presented to the ED, Triaged at 10:03 P.M. on 11/11/2022, was brought back to the ED at 3:13 A.M. on 11/12/2022 and transferred to a Pediatric Hospital at 1:18 P.M. on 11/13/2022 for new-onset diabetes. RN #3 said the child, received Tylenol in Triage for a fever of 101-102 degrees Fahrenheit, however the child waited in the waiting room for five hours without re-evaluation of pediatric ED nursing care needs.

Condition of Participation: Emergency Services

Based on records reviewed and interviews the Hospital failed to meet the emergency needs of Emergency Department patients.

Findings included:

1.) The Hospital Emergency Services failed to be integrated with other Hospital departments when responding to a Code Help.

Refer to TAG: A-1103.

2.) The Hospital failed to have adequate numbers of nursing personnel, i.e., enough Registered Nursing staff), qualified in Emergency Nursing Care, to meet the needs of Emergency Department patients.

Refer to TAG: A-1112.

Based on records reviewed and interviews the Hospital Emergency (ED) Services failed to be efficiently integrated with other Hospital departments to respond to a Code Help.

Findings included:

The Hospital policy titled Code Help, dated 11/23/2021, indicated a Code Help was initiated when the ED was unable to accept any new patients or was unable to care for exiting patients because the acuity impeded provision of safe patient care. Code Help was a Hospital wide response and mobilization of resources to improve patient flow through the ED, enhancing safety, quality and the patient experience. The Code Help policy indicated Hospital wide response included representation from Nursing, ED Nursing and ED Physician; Environmental, Laboratory, Radiology, Transport Services, and Case Management.

The CDOC/Code Help Tracking Report, dated 6/2022 through 10/2022, indicated a theme of non-attendance.

During the interview, at 9:30 on 11/9/2022, Registered Nurse (RN) #1 said Code Help was designed to decompress the ED however no one ever comes.

During the interview, at 2:00 P.M. on 11/15/2022, ED RN #3 said that no one else other than Housekeeping responded to an ED Code Help.

Based on records and interviews the Hospital failed for a total of four patients; two sampled patients (Patients #6, #7) and two unsampled patients (Unsampled Patients #1 & #4) to have adequate numbers of nursing personnel, i.e., enough Registered Nursing staff, qualified in Emergency Nursing Care, to meet the needs of Emergency Department (ED) patients.

Findings included:

1.) The Hospital Report, dated 8/12/2022, indicated Patient #6 waited in the Emergency Department (ED) waiting room for more than 14 hours, following a Triage assessment ESI of until brought to a room for treatment, due to low staffing on the night shift.

Patient #6's medical record indicated, at 5:52 P.M. on 8/12/2022, an RN Triaged Patient #6, Patient #6 suffered a Cerebral Vascular Accident (CVA, stroke) in April, now reported weight loss, weakness, decreased mobility and inability to ambulate; a fast heartbeat of 115 beats per minute, an oxygen saturation of 97 (normal) in room air and an ESI of 2.

The Hospital policy titled Emergency Department Nursing Triage, dated, 4/5/2022, indicated patients with an ESI of 2 required evaluation and treatment within minutes.

2.) The Hospital Report dated 10/8/2022, indicated Patient #7 was left in the ED waiting room for 17 hours with stroke symptoms, loss of vision in one eye and a history of strokes.

The Medical Record of Patient #7, indicated no RN documentation for approximately 17 hours, to ensure a Registered Nurse (RN) met the nursing care needs for this elderly ED patient with a faster than normal heartbeat, referred for evaluation of a likely Transient Ischemic Attack (TIA, precursor of a stroke).

Patient #7's medical record, dated at 1:13 P.M. on 10/7/2022, Patient #7 was triaged, two days ago the Patient had painless loss of vision in the left eye which had improved some since and now vision was haze. Patient #7 was seen today by an eye specialist who recommended follow-up for likely Transient Ischemic Attack (TIA, mini stroke caused by temporary disruption in blood supply to part of the brain).

3.) During the interview, at 11:30 A.M. on 11/16/2022, ED RN #3 said a 2-year-old child (Unsampled Patient #4), presented to the ED, waited in the waiting room for five hours before being brought back to the ED and transferred to a Pediatric Hospital with new-onset diabetes (pediatric new-onset diabetes, type 1 diabetes, can put a child at risk of serious complications, including hypoglycemia, hyperglycemia, diabetic ketoacidosis and death, requiring prompt medical attention, insulin must be taken daily).

During the interview, at 9:30 A.M. on 11/9/2022, ED RN #1 said there were patients without a nurse caring for the patients (details not reported); a trauma patient (Unsampled Patient #1) with a gun-shot wound, could not administer blood because there was no nurse to administer the blood, documentation was lacking (no one to document), no one to administer and manage multiple life-saving constant infusion medications. ED RN #1 said the other ten patients assigned to the two RN's caring for the trauma patient had no RN for approximately one hour.

During the interview, at 3:00 P.M. on 11/10/2022, ED RN #2 said things were getting worse, (we) do not hear how the Hospital was managing capacity issues, the Hospital needs to build and improve staffing, when there was a trauma patient "it's you", there were fifteen hour wait times and five day wait times for admissions, patients leave without being seen, the patient in room #12 had been without a nurse for one hour and this was not an uncommon occurrence, patients in the waiting room on oxygen (delivered by a tank), an RN manages the oxygen tank not a Respiratory Therapist.

During the interview, the Surveyor observed a crowded ED with patients in ED hallways: a patient having blood drawn, a patients abdomen, visitors, a Doctor in conversation with a patient and family, a patient urinal with urine on a bedside table, and patients in underwear.

During the interview, at approximately 2:00 P.M. on 11/15/2022. RN #3 said psychiatric patient were eloping (details not reported by RN #3) as Corporate told the Hospital to decrease Security staffing; the Triage Nurse was expected to monitor patients in the waiting room, take vital signs, and this was impossible to do.

During the interview, at 11:30 A.M. on 11/16/2022, RN #3 said she triaged one-hundred patients.

During the interview, at 11:00 A.M. on 11/17/2022, RN #3 said a patient waited in the waiting room for seven-teen hours without food, fluids and the venting machine was broken for over one year.

The Hospital provided no documentation to support the Hospital had adequate numbers of nursing personnel, i.e., enough Registered Nursing staff and ancillary staff qualified in Emergency Care, to meet the needs of Emergency Department (ED) patients.