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Based on interview, medical record review, and review of hospital policies and procedures, the hospital failed to ensure that patients placed in restraints or seclusion received a face-to-face assessment within 1 hour by a physician or trained licensed independent practitioner (LIP) or registred nurse (RN) as directed by hospital policy for 2 of 3 patients reviewed (Patients #4 and #5).

Failure to perform the required 1 hour face-to-face evaluation to evaluate whether the patient meets the specific criteria for restraint or seclusion places patients at risk of physical and/or psychological harm.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraints/Seclusion," PolicyStatID # 11271155, last revised 03/22, showed that the use of violent or self-destructive restraints or seclusion requires an in person face-to-face assessment conducted by a LIP or trained RN within 1 hour after application. The LIP generally completes the 1 hour face-to-face assessment for all seclusion and violent or self-destructive restraints applied in the emergency department (ED).

The policy showed that when applying violent or self-destructive restraints or seclusion on ED or pediatric patients, the LIP will conduct the face-to-face physical and behavioral assessment to address the patient's immediate situation, response to the restraint intervention, medical and behavioral condition, and the need to continue or remove the restraint. The provider will document the assessment in the patient's medical record.

2. On 11/30/22 at 12:58 PM, Investigators #2 and #3 and the Director of Regulatory Affairs (Staff #1) reviewed the medical records of Patient #4, a 10 year-old placed in restraints for violent or self-destructive behavior. Document review showed the following:

a. Patient #4 was placed in violent restraints on 11/20/22 at 10:14 AM. Investigators found no documentation that a face-to-face assessment was completed by a LIP within 1 hour of the restraint application as required by hospital policy.

b. Patient #4 was placed in violent restraints on 11/21/22 at 7:45 AM. Investigators found no documentation that a face-to-face assessment was completed by a LIP within 1 hour of the restraint application as required by hospital policy.

3. At the time of the review, Staff #1 verified the missing face-to-face assessment documentation.

4. On 11/30/22 at 1:39 PM, Investigators #2 and #3 and the Director of Regulatory Affairs (Staff #1) reviewed the medical records of Patient #5, an adult inpatient placed in locking 4-point restraints on 11/12/22 at 9:32 PM for violent behavior. Investigators found no documentation showing that a LIP or trained RN completed a face-to-face assessment as required by hospital policy.

5. At the time of the review, Staff #1 verified the missing face-to-face assessment documentation.

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Based on interview, record review, document review, and review of the hospital's policies and procedures, the hospital failed to ensure adequate and qualified staff for the provision of emergency care.

Failure to provide adequate and qualified staff for the delivery of emergency care places patients at risk for unsafe, incompetent, and poor quality emergency care.

Findings included:

1. Failure to provide adequate emergency department (ED) personnel to ensure that staff completed baseline and ongoing assessments according to hospital policy for 13 of 14 patient records reviewed.

2. Failure to ensure that all staff working in the ED received appropriate orientation to the unit for 2 of 10 employee records reviewed.

Cross-reference A 1112

Due to the scope and severity of deficiencies cited under 42 CFR 482.55, the Condition of Participation for Emergency Services WAS NOT MET.

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Item #1 Baseline and Ongoing Assessments

Based on observation, interview, and document review, the hospital failed to provide adequate emergency department (ED) personnel to ensure that staff completed baseline and ongoing assessments according to hospital policy for 13 of 14 patient records reviewed (Patients #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18).

Failure to provide adequate ED personnel to ensure that staff complete baseline and ongoing assessments places patients at risk for poor outcomes and death.

Findings included:

1. Review of the hospital policy titled, "Emergency Department Triage," PolicyStat ID# 9235213, last revised 02/21, showed that all patients presenting to the Emergency Department (ED) for evaluation via the lobby will receive a rapid visual assessment by the Greet Nurse. When immediate bedding is not available, a triage assessment should be completed as soon as possible using the triage room. A full triage assessment includes the following: chief complaint, brief history of symptoms, medical/surgical history, vital signs, level of consciousness, allergies, fall risk assessment, height and weight on all patients able to stand and all pediatric patients ages 14 and under, pediatric immunization status, domestic violence screen, early isolation screen, appropriate triage acuity assignment, and initiation of appropriate protocols. Patients awaiting medical evaluation will be reassessed per ED Standards of Care.

The hospital uses the 5 category Emergency Severity Index (ESI) triage system. The levels include:

· Level 1 - Life threatening
· Level 2 - Emergent
· Level 3 - Urgent
· Level 4 - Routine
· Level 5 - Non-Urgent

A Licensed Independent Practitioner (LIP) will evaluate the patients based on their chief complaint and provider availability. Patients awaiting medical evaluation will be reassessed per ED standards of care.

Review of the hospital policy titled, "Emergency Department Standards of Care," PolicyStat ID# 10748236, last revised 11/21, showed that patients in all areas of the ED will be assigned to a registered nurse (RN). Patient assignments will be made at the beginning of each shift using zone or geographical areas, with adjustments by the charge nurse for high acuity and high census.

Staff will obtain baseline vital signs including temperature, pulse, respiration rate, blood pressure, and pain on all adult patients, and a temperature, pulse respiration rate, and pain score on all pediatric patients (age 14 and younger). Staff will attempt to obtain a blood pressure on all pediatric patients, unless otherwise instructed by the provider, and document circumstances if unable to obtain.

An ongoing assessment will be performed at least every 2 hours for patients with an acuity level of 1, 2, and 3. The assessment will include vital signs (temperature, pulse, respiration rate, blood pressure, and pain scale), a focused assessment and level of consciousness, interventions, and responses.

Medications will be administered per LIP order, and patient responses to medications, including repeat vital signs as indicated should be assessed and documented. Patients should be observed in the ED for 20 minutes following the administration of any medications given intravenously (IV), intramuscularly (IM), or subcutaneously (SQ).

Staff will document any information obtained from the patient, family, or others that is pertinent to the condition or care of the patient. Documentation will include all responses to treatments and interventions, understanding of discharge instructions, and any attempts, including the time and number of attempts made, to locate patients in the lobby and adjacent areas, when it appears a patient has left without being seen.

2. On 11/29/22 at 1:53 PM, observation showed the ED lobby staffed with one greet nurse, one ED Flow Tech, and one admitting representative with 33 ED patients, including 17 patients waiting for triage, 3 patients triaged and waiting for medical evaluation, and 13 patients who were seen by the medical provider and were waiting further care before discharge or admission.

3. On 11/29/22 at 2:01 PM, an interview with the ED Clinical Nurse Educator (Staff #5) showed that the Greet RN greets patients as they arrive in the ED lobby, performs a rapid assessment, and assigns the patient ESI level. Staff #5 stated that if there is a delay with the triage process, the Greet RN will perform the full triage assessment. While greeting and assessing new ED arrivals, Staff #5 stated that the Greet RN was also responsible for scanning the waiting room to watch for patients who appear distressed. Staff #5 stated that the ideal staffing model included an ED tech assigned to the lobby who would take vital signs of new arrivals and patients waiting to be seen, obtain equipment, and help patients with emergencies as needed.

4. On 11/30/22 between 9:00 AM and 10:15 AM, investigators interviewed 3 ED staff about the processes for patients waiting for treatment in ED lobby (Staff #14, #15, and #16). The interviews showed the following:

a. All staff stated that Greet Nurse and Flow Tech conducted assessments and reassessments on patients waiting to be seen by a provider. Staff stated that once the patient receives a medical screening exam, the Triage Nurse or Tech is responsible for obtaining patient vital signs and completing the ongoing assessments. Only 1 of 3 ED staff interviewed (Staff #15) could verbalize the hospital's policy for completing ongoing assessments at least every 2 hours for patients with ESI acuity scores of 1, 2, and 3.

b. Staff #14 and #15 stated that other than reviewing each patient's medical record, the hospital did not have a smooth process for tracking when a patient in the ED lobby was due for vital signs or reassessment. Both Greet Nurses (Staff #15 and #16) stated that they would frequently prioritize checking in and triaging patients over completing reassessments or verifying that the Flow Tech checked patient vital signs. Staff #15 and #16 attributed their failure to complete ongoing assessments and documentation according to hospital standards to inadequate ED staffing levels, high volumes of ED Boarders (ED patients with orders to admit who remain in the ED longer than 4 hours) and an overall increased demand for emergency care services. Staff #15 and #16 stated that the hospital started a "Zero Boarder" policy a couple of weeks ago, that was helpful in reducing the volumes, but inpatient units did not like it, and they stopped following it after a few weeks.

5. On 11/29/22 between 9:30 AM and 11:47 AM, Investigators #2, #3, and #13 interviewed the Director of Regulatory Affairs (Staff #1) and 2 Patient Safety Consultants (Staff #2 and #4) while reviewing hospital quality improvement documents. Document review and interview showed the following:

a. On 06/23/22, the ED was holding 72 boarders, and there were 52 patients in the waiting room with one Greet Nurse. Staff #4 stated that the hospital reviewed video of the ED waiting room from 06/22/22 to 06/23/22 and found that ED staff did not perform timely triage, assessments and reassessments according to hospital policy and did not meet its standard of care.

b. On 11/03/22, the ED was holding 47 borders, and there were 39 patients in the waiting room with one greet nurse. Staff #4 stated that the hospital reviewed video of the ED waiting room from 11/02/22 to 11/03/22 and found that the hospital did not perform assessments and reassessments according to hospital policy and did not meet its standard of care.

c. On 11/04/22, the Chief Nursing Officer emailed all nursing leadership the hospital's policy for "Zero Boarding" of ED patients. The document showed a plan to ease the high ED patient volumes by focusing on timely and early written discharges throughout the hospital and transferring patients to their respective inpatient units from the ED to the inpatient units. Staff #1 stated that the plan worked well at first, but the inpatient units were unhappy with the higher patient to nurse ratios.

6. Investigators #2 and #3 and the Director of Risk and Accreditation (Staff #1) reviewed the medical records of 14 patients treated in the ED between 06/23/22 and 11/30/22. All patient records reviewed showed ESI acuity score of 2 or 3 on the day of the visit. The record review showed the following:

a. Staff failed to obtain a baseline set of vital signs as required by hospital policy for 5 of 14 patient records reviewed (Patients #9, #10, #12, #15, and #17).

b. Staff failed to reassess patients with ESI acuity scores of 2 - 3 a minimum of every 2 hours as required by hospital policy for 12 of 14 patient records reviewed (Patients #6, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, and #18).

c. Staff failed to reassess patients within 20 minutes following the administration of intravenous (IV) medication for 4 of 14 patient records reviewed (Patients #7, #12, #13, #17).

d. During the record review, Staff #1 confirmed the investigators' finding's of the missing documentation.


Item #2 Department Orientation

Based on interview, document review, and review of hospital policies and procedures, the hospital failed to ensure that staff working in the Emergency Department (ED) received appropriate departmental orientation for 2 of 10 employee files reviewed (Staff #1305 and Staff #1310).

Failure to validate successful completion of a department orientation can lead to nurses' inability to provide quality, competent, and safe nursing care in accordance with professional practice requirements.

Findings included:

1. Review of the hospital policy titled,"Education Plan Acute Care Medical Telemetry/Surgical," revised 09/22, showed that individuals may cross orient to other units based upon unit requirements and personnel need. Orientation would be based on skill level and experience.

2. Review of the UFCW 21 and Providence Regional Medical Center Everett union contract, effective until 10/30/23, showed that nurses could be temporarily assigned (floated) to any staff nurse position within the Medical Center. Nurses who are required to float will have received orientation appropriate to the assignment and would be dependent upon the nurse's previous experience and familiarity with the nursing unit and patient assignment. Each floated nurse would receive orientation to the unit and would be assigned a resource person from the unit's permanent staff for clinical guidance as needed.

3. During an interview with investigator #13 on 11/29/22 at 2:22 PM, a registered nurse from the Pediatric Department (Staff #1305) stated that on Friday, 11/25/22, they were notified by the hospital that on Monday, 11/28/22, they would be working in the ED taking care of inpatient boarders. They stated that they did not receive any orientation to the physical department, or expectations for working in that area.

4. During an interview with investigator #13 on 11/30/22 at 9:35 AM, a registered nurse from the Pediatric Department (Staff # 1310) assigned to work in the ED stated that they had not received any orientation to the unit, and they did not know where supplies were kept, so when they needed supplies for their patients, they ran back up to the Pediatric unit to get them.

5. Review of employee files showed that 2 of 10 employees did not receive orientation to their assigned work area (ED) (Staff #1305 and Staff #1310). The result was verified during the review with the Human Resources generalist (Staff #1312) and the Director of Medical Staff Services and Regulatory Affairs (Staff #1301).
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