HospitalInspections.org

Based on the review of clinical records, policies and procedures, hospital documents, medical records, observations, and staff interviews, it was determined that the Governing Body failed to ensure that the hospital operations, functions, and responsbilities are able to provide a safe and healthy environment for the patient population. These deficient practices pose a potential risk for patients of receiving inadequate care and treatment timely, which could lead to avoidable lengthy patient admissions, unwarranted development of disease complications, and probable poor patient prognosis.

Cross reference:A-0057: The Governing Body failed to ensure that the Chief Executive Officer (CEO) was responsible for hospital operations.

Cross reference: A-0143: The hospital failed to ensure there was adequate privacy for patients with care and treatment.

Cross reference: A-0286: The hospital failed to ensure corrective action plans were developed and implemented to improve and prevent the amount of patient care incidents.

Cross reference: A-0315: The hospital failed to ensure the hospital was provided with adequate personnel and resources to provide the adequate scope of services and care to patients.

Cross reference: A-0386: The Governing Body failed to ensure the Chief Nursing Officer (CNO) was responsible for the operation of nursing services.

Cross reference: A-0392: The hospital failed to ensure sufficient staffing was provided to:
1. prevent patient care incidents
2.ensure appropriate nurse patient ratios in the Intensive Care Unit.

Cross reference: A-0398: The hospital failed to ensure nursing personnel followed policies and procedures when providing patient care to five (5) patients.

Cross reference: A-0750: The hospital failed to ensure:
1. Staff followed isolation protocols with wearing personal protective equipment (PPE).
2. Staff were performing proper hand hygiene.
3. Patients rooms are cleaned daily

Cross reference: A-1110: The hospital failed to ensure that the Emergency Department had sufficient staffing to ensure:
1.patients are triaged upon arrival to the Emergency Department (ED)
2.medical screening examinations are performed on patients in a timely manner.
3.patients are not treated for emergency conditions in the hallway.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for the Condition of Participation for Governing Body.

Based on review of job descriptions, policies and procedures, document review, medical record review, and interview, it was determined the Chief Executive Officer (CEO) failed to manage the daily operation of the hospital. This deficient practice poses a risk to the health and safety of patients when leadership does not provide proper guidance, enforcement of policies and procedures and provide resources to provide care to meet the needs of patients.

Findings include:

Hospital document tited, "Job Description- Chief Executive Officer", revealed: "...CORE FUNCTIONS: This position has overall accountability for producing desired results associated with service excellence, quality clinical outcomes, market share maintenance/expansion, and financial integrity of operations at assigned medical facility or complexes, being highly visible at the facility, region and system levels, and includes the development and management of campus growth and improvement plans, efficient utilization of resources, acquisition of technology, and program development...Maintains a service excellence and healing culture with high expectations established for positive patient experiences...Serves as a leaderTwenti in developing the Continuous Quality Improvement process, in educating staff and role modeling Service Excellence, and in assisting with cultural transformation...Works with medical staff to assure the provision of facilities and services that fosters a high level of professional practice and responsiveness to the needs of the community, including high quality patient health care and desired medical management outcomes...Implements, through management and leadership staff, a Patient Safety Plan that: fosters an environment that focuses on processes and outcomes rather than individual blame; ensures that safety is a priority in design and redesign of new services; allocates financial, informational, physical and human resources for improvement activities; and assures patient and family disclosure of "untoward outcomes."...This highly complex and dynamic role has full executive leadership for an assigned medical facility and/or medical complex/center(s), ranging from a large campus in a metropolitan area with Level I trauma, high-risk neonatal, transplantation services, and medical teaching facility to a small community hospital. Attains and monitors a complex mix of services and innovations necessary to sustain a competitive advantage and achieve pre-eminence for the hospital in its community in a fast-moving healthcare environment...Scope of responsibility includes leading facility operational planning, consistent with organizational priories, to identify and reach short and long-term goals and overseeing day-to-day operations of assigned facility...."

During the survey it was determined the CEO failed to perform the core functions of the CEO as demonstrated by the following:

Cross reference: A-0143: The hospital failed to ensure there was adequate privacy for patients with care and treatment.

Cross reference: A-0286: The hospital failed to ensure corrective action plans were developed and implemented to improve and prevent the amount of patient care incidents.

Cross reference: A-0315: The hospital failed to ensure the hospital was provided with adequate personnel and resources to provide the adequate scope of services and care to patients.

Cross reference: A-0386: The hospital failed to ensure the Chief Nursing Officer (CNO) was responsible for the operation of nursing services.

Cross reference: A-0392: The hospital failed to ensure sufficient staffing was provided to:
1. prevent patient care incidents
2.ensure appropriate nurse patient ratios in the Intensive Care Unit.

Cross reference: A-0398: The hospital failed to ensure nursing personnel followed policies and procedures when providing patient care to five (5) patients.

Cross reference: A-0750: The hospital failed to ensure:
1. Staff followed isolation protocols with wearing personal protective equipment (PPE).
2. Staff were performing proper hand hygiene.
3. Patients rooms are cleaned daily

Cross reference: A-1110: The hospital failed to ensure that the Emergency Department had sufficient staffing to ensure:
1.patients are triaged upon arrival to the Emergency Department (ED)
2.medical screening examinations are performed on patients in a timely manner.
3.patients are not treated for emergency conditions in the hallway.

Employee #15 confirmed on 03/30/2023 the CEO was responsible for the daily operation of the hospital.

Based on policy and procedure review, hospital document and staff interview, it was determined the Hospital failed to ensure there was adequate privacy for patients with care and treatment. This deficient practice poses a risk to the health and safety of patients when the facility does not respect the patients right to privacy and confidentiality.

Cross reference: A-0043, A-0057, A-0315, A-0385, A-0386, A-0392, A1100, A-1110

Finding Include:

Hospital document titled, "Patients' Rights and Responsibilities", revealed: "...Your Right to Privacy and Confidentiality: You have the right to: Verbal and physical privacy as much as is reasonably possible...."

Observation on tour on 03/29/2023 revealed multiple patients on all inpatient units receiving patient care such as dressing changes, foley catheter being emptied, and suctioning without the door shut to the patient room or the curtain pulled to provide privacy. Observation on tour on 03/29/2023 revealed multiple patients on all inpatient units lying in bed with gowns pulled up and bedding not covering the patient and the door to the patient rooms were open. Observation in the ICU revealed a patient having a central line placed with the door closed to the room but the window blinds had not been pulled.

Observation on tour of the Emergency Department (ED) on 03/29/2023 revealed Patient #4 lying a stretcher in the hallway of the Purple Zone with a family member sitting in a chair next to the patient. Multiple empty rooms were observed empty in the ED at the time the patient was observed in the hallway.

Observation on tour on 04/03/2023 revealed patients on the inpatient units changing hospital gowns without the curtains pulled or the door to the room closed. Employee #9 was observed closing the door to one patient's room after the surveyor walked by.

Based on the record review and interviews, it was determined the hospital failed to have a quality assessment and performance improvement program that reflected the complexity of the hospital's organization and services involving all hospital departments as evidenced by:

Cross reference: A-0286: failure to ensure corrective action plans were developed to improve and prevent the amount of patient care incidents.

Cross reference: A-0315: failure to ensure that adequate resources were allocated to improve and sustain the hospital's performance and reduce risks to patients.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation for Quality Assessment and Performance Improvement.

Based on policy and procedure review, hospital documents, and staff interview, it was determined the Hospital failed to ensure corrective action plans were developed and implemented to improve and prevent the amount of patient care incidents. This deficient practice poses a risk to the health and safety of patients when the facility does not implement actions to prevent adverse patient care incidents.

Cross reference: A-0263, A-0315, A-0392

Repeat citation from Event #WP5G11 07/12/2022

Findings include:

Policy titled, "Adult Patient Care", revealed: "...F. Risk Assessment-Risk Assessments for inpatient completed per protocol ...2. Patient Mobility (BMAT)-per shift 3. Fall Risk (Morse Scale)-upon admission, at change of caregiver or level of care, change in mental status, and after an actual fall .... "

Policy titled, " Fall Precaution Policy " , revealed: " ...III Policy: C. Fall Prevention is performed by hospital staff ...2. If patient meets Pre-fall huddle criteria, mandatory intervention in place b. Caregiver assistance when ambulating ...c. Door identification via call light system or signage...."

Policy titled, "Management of Staffing Resources (Acute Facilities)", revealed: "...Less than optimal: Deficit of staff members on a unit or in a department; based on staffing plan or anticipated units of service and anticipated acuity...The patient acuity score provides information to guide the nurse-patient assignment, aligning staff resources with patient care needs...Daily staffing is based on patient needs and the staffing and acuity plan...Staffing assignments are accomplished by maximizing available personnel to meet the needs of patients based on: a. patient acuity; b. patient census; c. availability of staff resources; d. staff competency and skill mix; e. hospital-wide needs...Arizona Adult Critical Care only: When the primary nurse is unable to give direct care to their patient due to a situation which may require the nurse to leave the ICU department, (i.e., diagnostic procedures, meal breaks, code arrest coverage, trauma call, etc.) Assignments may be adjusted as follows: i. the charge nurse or designee will designate another RN to temporarily assume responsibility of the patient, ii. the RN assuming temporary responsibility of ICU level patients may be responsible for 2 assigned patients plus one temporary reassigned patient...iv. Non-ICU level of care patients being care for in the ICU will have temporary coverage assigned as appropriate to the acuity of the patients but maintaining that any RN caring for ICU patients will not be responsible for more than 3 patients at a time on a temporary basis...."

The staffing acuity matrix was not provided by the facility.

Hospital document titled, "Banner Mobility Assessment Tool (BMA)", revealed: "...Mobility Assessment Level 3: Stand Assessment of Lower Extremity Strength for Standing ...Can the patient do ALL the following action yes or no Elevate off the bed/chair (seated or standing) with or without assistance device (i.e. cane or bedrails) Able to raise buttocks off bed and hold for 5 seconds. May repeat once ...Does the patient ambulate without assistive devices? Does the patient display safety awareness and orient x3 ...Mobility Assessment Level 4: Modified Independence Assessment of Standing Balance and Gait ...Can the patient do ALL the following actions? Yes or no. March in place at bedside. Advance step and return each foot (step backwards) .... "

Hospital document titled, "BBMC Event Log", revealed fourteen (14) patient falls between 01/17/2023 and 03/28/2023 that were accounted to "low staffing", "staffing below goal", "less than optimal staffing" or "staffing assignments busy with high acuity patients" as reasons for why fall occurred.

One (1) patient fall on 02/01/2023 was attributed to patient required a companion/sitter and one was not available.

One (1) patient fall on 03/07/2023 was attributed to not enough staff and "will add a companion when staffing allows."

One (1) patient fall on 03/11/2023 was attributed to "unsure why the bed alarm was not on. There were only 2 PCAs for 23 patients, 4 RNs so staffing was very busy. Charge nurse had 5 patients and this room."

Further review of the "BBMC Event Log" revealed on 03/07/2023 a patient was left unattended on a gurney with no call light in an unlit room in radiology. Further review of the incident revealed the patient had transfer orders from the ICU to Medical/Surgical 6th floor at time of transport to radiology for a radiology exam. Radiology department staff called for transport, were unaware that patient had not been picked up by transport. ICU staff and Medical Surgical staff unaware patient was unattended in radiology. "Units busy" was reason for the incident occurring.

Further review of the "BBMC Event Log" revealed two (2) patients developed wound care issues:
On 01/18/2023 it was discovered that one (1) patient's chest tube dressing had not been changed for five (5) days. Policy is that chest tube dressings are changed every 72 hours. The reason indicated for the chest tube dressing not being changed was "not enough staff".

One (1) patient on 03/21/2023 developed a hospital acquired pressure injury in the buttocks area due to urine soaked briefs not being changed when the patient soiled the briefs. The reason indicated on the log for how the incident occurred was "staff too busy with other patients."

Review of the "BBMC Event Log" revealed one (1) laboratory error in which a patient was on a heparin drip and coagulation factor lab was ordered to be drawn at 0830. The lab was not drawn until 1830. The reason for the missed lab work was the "nurse had five (5) patients and patient acuity and workload was high. Staffing was less than optimal this shift."

Further review of the "BBMC Event Log" revealed sixteen (16) patients that their telemetry monitors were off for one (1) to three (3) hours due to batteries needing to be changed. Further review of the incident log revealed the reason the telemetry monitor batteries were not changed in a timely manner "change of shift", "staff busy", "lack of staff".
Further review of the "BBC Event Log" revealed no evidence of implementation of action plans to decrease the number of incidents.

Review of the "BBMC Event Log" under the "what was done to prevent it from happening again" tab revealed: 1. no action response documented; 2. reviewed policy with staff; 3. educated patient to call for assistance/educated patient on fall precautions; 4. reminder to staff to keep bed alarms on; 5. reviewed in huddle with staff telemonitors need to be attached to patient; 6. discussion on how we can cover when short staffed.

Review of the Nursing Schedules/Staffing Assignments revealed that for each patient care unit, on most days each nurse had five (5) patients assigned. Each patient care tech was assigned twelve (12) to fourteen (14) patients. Several days a week, charge nurses were in ratio assigned one (1) to four (4) patients.

A request was made for the hospital's Quality Council Meeting Minutes for the past year. Quality Council Meeting Minutes were provided from January to December 2022. Review of the Quality Council Meeting Minutes from September 2022 revealed falls were being monitored and more information would be presented at the December 2022 meeting. A review of the December 2022 Quality Council Meeting Minutes revealed no evidence that Patient Falls Data was presented and reviewed.

Observation conducted on 03/29/2023 every room had a fall risk sign displayed. There are 3 different colors: green for universal fall risk and Morse Fall Score of 0-44; yellow for High Fall Risk and Morse Fall Score of greater than 45; Red for Pre-Fall Huddle Criteria which is based upon Nursing discretion, Morse Fall Score could be Universal or High.

Observation on tour on 03/29/2023 revealed a Performance Improvement bulletin board on the 4th floor revealed the number of patient falls for the week of 03/19/2023 through 03/27/2023 revealed one (1) patient fall for that floor.
Employee #1 confirmed that the bulletin board was a type of dashboard so staff could observe the number of falls that were occurring on the unit and take ownership of patient falls. Employee #1 did not provide any information on quality control for patient care incidents.

Patient #4 and Patient #4 family representative confirmed on 03/29/2023 that staffing "does not appear to be sufficient". Patient #4 family representative confirmed that often s/he will have to assist Patient #4 with cares as staff are not available.

The family representative of Patient #7 confirmed during an interview conducted on 04/03/2023 that they have helped Patient #7 ambulate out of bed to use the toilet. Patient #7's family representative did not receive any guidance or instruction of how to ambulate Patient #7 out of the bed. Patient #7 is under fall precautions.

Employee #1 confirmed on 03/28/2023 that when a patient that is considered a fall risk and ambulates that a caregiver is to assist the patient.

Employee #1 confirmed on 03/29/2023 that staffing continues to be a struggle to fill empty staff positions. Employee #1 confirmed that the usual nurse to patient ratio based on acuity is 1:5.

Based on the review of policies and procedures, hospital documents, and staff interviews, it was determined the Governing Authority failed to ensure that the hospital was provided with adequate personnel and resources to provide the adequate scope of services and care to patients. This deficient practice poses a risk to the health and safety of patients if the hospital is unable to provide the proper care and resources to meet the patient's medical needs.

Cross reference: A-0043,A-0057, A-0286,A-0385, A-0386, A-0392, A-1100

Findings include:

Hospital policy titled, "EMTALA-Medical Screening Examination and Stabilization Treatment", revealed: "...Medical Screening Examination ("MSE"): An appropriate MSE will be offered to individuals on the Campus of Banner Hospitals with a Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested...When an EMS provider brings an individual to the Hospital with Dedicated Emergency Department and the Hospital does not have the capacity or capability to provide an immediate medical screening exam, and if needed, stabilizing or an appropriate transfer, the Hospital must still assess the individual upon arrival to ensure that the individual is appropriately prioritized based on presenting signs and symptoms. Hospital should assess whether the EMS can appropriately monitor the individual's condition...Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSE...An MSE will be conducted to determine whether the Patient has an EMC (emergency medical condition)...The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions...."

Hospital policy titled, "Emergency Department Patient Care", revealed: "...Triage Assessment: Completed by a RN, Paramedic or QMP. If a Paramedic is used to expedite the triage to assist with high patient volume, the RN oversees the ESI scoring, care plan of the patient and utilizes standing orders when needed...An Emergency Severity Index (ESI) score is assigned when the triage assessment is completed. ESI 1= Requires immediate life-saving interventions; ESI 2= High risk situation or confused/lethargic/disoriented or severe pain distress; ESI 3= Two or more resources may be needed; ESI 4= One resource may be needed; ESI 5= No resources needed...ED triage documentation may include, but is not limited to: Chief complaint, vital signs, pain, and oxygenation; Mode arrival and mechanisms of injury; Triage assessment and ESI scoring; Infectious Disease Screening; Suicide Screening...A medical screening exam (MSE) is completed by an Emergency Physician or QMP...When applicable, the ED Medical Provider and/or QMP will complete the MSE in conjunction with an RN or Paramedic as a joint assessment...Both the ED Medical Provider and/or QMP and RN or Paramedic perform a complaint specific assessment to prioritize, treat and evaluate for emergent, urgent, and non-urgent patients...Patient arriving from all portals of entry into the ED will receive a baseline assessment of their chief complaint by a registered nurse, physician or designee...An ESI score will be assigned based upon acuity and resources needed...Patients assigned ESI level 1 & 2 will be given placement priority...These priorities may be modified throughout the patient encounter as diagnostic testing/findings are made available and intervention/treatments are evaluated for effectiveness...."

Policy titled, "Management of Staffing Resources (Acute Facilities)", revealed: "...Less than optimal: Deficit of staff members on a unit or in a department; based on staffing plan or anticipated units of service and anticipated acuity...The patient acuity score provides information to guide the nurse-patient assignment, aligning staff resources with patient care needs...Daily staffing is based on patient needs and the staffing and acuity plan...Staffing assignments are accomplished by maximizing available personnel to meet the needs of patients based on: a. patient acuity; b. patient census; c. availability of staff resources; d. staff competency and skill mix; e. hospital-wide needs...Arizona Adult Critical Care only: When the primary nurse is unable to give direct care to their patient due to a situation which may require the nurse to leave the ICU department, (i.e., diagnostic procedures, meal breaks, code arrest coverage, trauma call, etc.) Assignments may be adjusted as follows: i. the charge nurse or designee will designate another RN to temporarily assume responsibility of the patient, ii. the RN assuming temporary responsibility of ICU level patients may be responsible for 2 assigned patients plus one temporary reassigned patient...iv. Non-ICU level of care patients being care for in the ICU will have temporary coverage assigned as appropriate to the acuity of the patients but maintaining that any RN caring for ICU patients will not be responsible for more than 3 patients at a time on a temporary basis...."

The staffing acuity matrix was not provided by the facility.

Hospital document titled, "BBMC Event Log", revealed fourteen (14) patient falls between 01/17/2023 and 03/28/2023 that were accounted to "low staffing", "staffing below goal", "less than optimal staffing" or "staffing assignments busy with high acuity patients" as reasons for why fall occurred.

One (1) patient fall on 02/01/2023 was attributed to patient required a companion/sitter and one was not available.

One (1) patient fall on 03/07/2023 was attributed to not enough staff and "will add a companion when staffing allows."

One (1) patient fall on 03/11/2023 was attributed to "unsure why the bed alarm was not on. There were only 2 PCAs for 23 patients, 4 RNs so staffing was very busy. Charge nurse had 5 patients and this room."

Further review of the "BBMC Event Log" revealed on 03/07/2023 a patient was left unattended on a gurney with no call light in an unlit room in radiology. Further review of the incident revealed the patient had transfer orders from the ICU to Medical/Surgical 6th floor at time of transport to radiology for a radiology exam. Radiology department staff called for transport, were unaware that patient had not been picked up by transport. ICU staff and Medical Surgical staff unaware patient was unattended in radiology. "Units busy" was reason for the incident occurring.

Further review of the "BBMC Event Log" revealed two (2) patients developed wound care issues:

On 01/18/2023 it was discovered that one (1) patient's chest tube dressing had not been changed for five (5) days. Policy is that chest tube dressings are changed every 72 hours. The reason indicated for the chest tube dressing not being changed was "not enough staff".

One (1) patient on 03/21/2023 developed a hospital acquired pressure injury in the buttocks area due to urine soaked briefs not being changed when the patient soiled the briefs. The reason indicated on the log for how the incident occurred was "staff too busy with other patients."

Review of the "BBMC Event Log" revealed one (1) laboratory error in which a patient was on a heparin drip and coagulation factor lab was ordered to be drawn at 0830. The lab was not drawn until 1830. The reason for the missed lab work was the "nurse had five (5) patients and patient acuity and workload was high. Staffing was less than optimal this shift."

Further review of the "BBMC Event Log" revealed sixteen (16) patients that their telemetry monitors were off for one (1) to three (3) hours due to batteries needing to be changed. Further review of the incident log revealed the reason the telemetry monitor batteries were not changed in a timely manner "change of shift", "staff busy", "lack of staff".

Review of the Nursing Schedules/Staffing Assignments revealed that for each patient care unit, on most days each nurse had five (5) patients assigned. Each patient care tech was assigned twelve (12) to fourteen (14) patients. Several days a week, charge nurses were in ratio assigned one (1) to four (4) patients.

Review of the ICU Nursing Schedules/Staffing sheets revealed on these dates and shifts:
02/13/2023 day shift: one (1) nurse for rooms 212 and 213
02/13/2023 day shift: one (1) nurse for rooms 214 and 215
02/13/2023 day shift: one (1) nurse for rooms 218 and 220
02/13/2023 night shift: one (1) nurse for rooms 212, 215, 218
02/14/2023 day shift: one nurse for rooms 213 and 214
02/14/2023 day shift: one nurse for rooms 218 and 220
02/15/2023 day shift: one (1) nurse for rooms 221 and 222
02/15/2023 day shift: one (1) nurse for rooms 223 and 224
02/15/2023 night shift: one (1) nurse for rooms 221, 222, and 223
02/15/2023 night shift: one (1) nurse for rooms 224 and 225

Review of Emergency Department Activity Logs for January, February, and March revealed a delay in patient triage and medical screening examinations (MSE) being performed. Review of the following patients' medical records revealed the following arrival to MSE times:

Patient #10 was registered on 02/14/2023 at 2345, triaged at 0034 and a medical screening examination (MSE) was performed at 01:10. The arrival time to triage time was 49 minutes. The door to doctor time was 1 hour 25 minutes. Patient #10 was assigned an Emergency Severity Index (ESI) score of 2.

Patient #11 was registered on 1/10/2023 at 2355, triaged at 0044 and a MSE was performed at 0202. The arrival time to triage tme was 51 minutes. The door to doctor time was 2 hours and 7 minutes. Patient #11 was assigned an ESI of 3.

Patient #14 was registered on 01/06/2023 at 1627, triaged at 1631 and a MSE was performed at 2031. The arrival to triage time was 4 minutes. The door to doctor time was 4 hours and 4 minutes. Patient #14 was assigned an ESI of 2.

Patient #15 was registered on 01/04/2023 at 0726, triaged at 0740 and a MSE was performed at 1044. The arrival to triage time was 14 minutes. The door to doctor time was 3 hours and 18 minutes. Patient #15 was assigned an ESI of 3.

Patient #16 was registered on 03/13/2023 at 2338, triaged at 2340, and a MSE was performed at 0506. The arrival to triage time was 2 minutes. The door to doctor time was 5 hours and 28 minutes. Patient #16 was assigned an ESI of 3.

Observation on tour of the Emergency Department on 03/29/2023 revealed one (1) patient (Patient #4) lying on a stretcher in the hallway and the patient's family member sitting in a chair next to the gurney. Multiple empty rooms were observed at the time in the ED.

Employee #9 confirmed on 03/29/2023 that Patient #4 was receiving treatment in the ED hallway. Employee #9 confirmed that there were empty rooms available but the rooms were monitored rooms and they were reserved for potential incoming patients that required monitoring. Employee #9 stated Patient #4 did not require a monitored bed and there were only so many monitored beds in the zone Patient #4 was in. Employee #9 stated that Patient #4 could be moved to a different zone that had unmonitored beds but there was not enough staff to open another patient care zone.

Employee #9 confirmed on 03/29/2023 that delays in triage and medical screening examinations is due to lack of staffing and room availability, especially if the Emergency Department is holding patient admissions to inpatient units because the inpatient units do not have the staff to care for the patients.

Patient #4 and Patient #4 family representative confirmed on 03/29/2023 that staffing "does not appear to be sufficient". Patient #4 family representative confirmed that often s/he will have to assist Patient #4 with cares as staff are not available.

The family representative of Patient #7 confirmed during an interview conducted on 04/03/2023 that they have helped Patient #7 ambulate out of bed to use the toilet. Patient #7's family representative did not receive any guidance or instruction of how to ambulate Patient #7 out of the bed. Patient #7 is under fall precautions.

Employee #1 confirmed on 03/28/2023 that when a patient that is considered a fall risk and ambulates that a caregiver is to assist the patient.

Employee #1 confirmed on 03/29/2023 that staffing continues to be a struggle to fill empty staff positions. Employee #1 confirmed that the usual nurse patient ratio based on acuity is 1:5.

Employee #8 confirmed on 03/29/2023 that nurse patient assignments in the ICU are 1 to 1 or 1 to 2.

Based on the review of hospital policies and procedures, documents, medical records observations, and interviews, it was determined that the Hospital failed to meet the requirement of the Conditions of Participation for Nursing Services as evidenced by the following references to standard-level deficiencies:

Cross reference: A-0143: The hospital failed to provide adequate privacy to patients with care and treatment.

Cross reference: A-0315: The hospital failed to provide sufficient staff and equipment to provide care to meet the needs of patients.

Cross reference: A-0392: The hospital failed to ensure sufficient staffing was provided to:
1. prevent patient care incidents
2.ensure appropriate nurse patient ratios in the Intensive Care Unit.

Cross reference:A-0398: The hospital failed to ensure nursing personnel followed policies and procedures when providing patient care to five (5) patients.

Cross reference: A-0750: The hospital failed to ensure:
1.Staff followed isolation protocols with wearing personal protective equipment (PPE).
2.Staff were performing proper hand hygiene.
3.Patients rooms are cleaned daily

Cross reference: A-1110: The hospital failed to ensure that the Emergency Department had sufficient staffing to ensure:
1.patients are triaged upon arrival to the Emergency Department (ED)
2.medical screening examinations are performed on patients in a timely manner.
3.patients are not treated for emergency conditions in the hallway.

The cumulative effect of these systemic deficient practices resulted in the facility's failure to meet the requirement for Condition of Participation in Nursing Services.

Based on the review of policies and procedures, hospital documents, medical records, observations, and staff interviews, it was determined the Chief Nursing Officer failed to manage the overall operations of the nursing services of the facility. This deficient practice poses a potential risk to the health and safety of patients if a lack of continuous nursing supervision in the provision of quality patient care to meet the needs of patients is provided in a timely manner, ensuring staffing was adequate to address the needs of the patient population, and establishing of policies and procedures for nursing staff adherence and proper surveillance of its implementation to preserve, maintain, and support the patient's physical and mental well-being.

Findings include:

Hospital document titled, "Senioer Director, CNO, Large Facility", revealed: "...This position has overall accountability for providing leadership, direction, and administration of day-to-day operations associated with direct
patient care activities and clinical education and development, including continuous improvement of nursing services and staff to meet the needs and expectations of those served by the System, at assigned facility or campus while maintaining a high level of visibility at the facility, region and system levels. Ensures the realization of quality and economical health care services within established facility and system guidelines and philosophies. This position is responsible for driving, supporting and modeling a service-oriented culture focused on employee engagement, quality, patient safety, service excellence, fiscal responsibility, and the overall patient experience...CORE FUNCTIONS: Maintains a working knowledge of current clinical practice and the regulatory requirements affecting that practice and exhibits the value of continuous learning. Demonstrates an in depth knowledge of healthcare economics and policy as well as the role of the governing body in the organization. Establishes and enhances a culture of evidence-based decision making in clinical and management initiatives. Articulates and models an emphasis on patient quality and safety. Understands utilization management and case management and their importance t the organization. Demonstrates this understanding by effectively managing risk...Provides leadership, supervision, guidance and development for staff, articulating and demonstrating an expectation for continuous quality improvement, as well as continually supporting and exhibiting company values and service standards...Strategizes and drives process improvements focused on innovative care delivery and/or operational models designed to improve clinical
services, outcomes, patient throughput, and patient safety. Promotes a patient-centered, healing environment...This position has administrative leadership responsibilities and is directly accountable for the quality and appropriateness of nursing care delivered to patients and contributes to the continuous improvement of nursing services and staff...."

During the survey it was determined the Chief Nursing Officer failed to perform the core functions of the position as demonstrated by the following:

A-0143: The hospital failed to provide adequate privacy to patients with care and treatment.

A-0315: The hospital failed to provide sufficient staff and equipment to provide care to meet the needs of panageatients.

A-0392: The hospital failed to ensure sufficient staffing was provided to:
1. prevent patient care incidents
2.ensure appropriate nurse patient ratios in the Intensive Care Unit.

A-0398: The hospital failed to ensure nursing personnel followed policies and procedures when providing patient care to five (5) patients.

A-0750: The hospital failed to ensure:
1.Staff followed isolation protocols with wearing personal protective equipment (PPE).
2.Staff were performing proper hand hygiene.
3.Patients rooms are cleaned daily

A-1110: The hospital failed to ensure that the Emergency Department had sufficient staffing to ensure:
1.patients are triaged upon arrival to the Emergency Department (ED)
2.medical screening examinations are performed on patients in a timely manner.
3.patients are not treated for emergency conditions in the hallway.

Employee #15 confirmed on 03/30/2023 the CNO was responsible for the operation of nursing services.

Based on review of policies and procedures, hospital documents and staff interviews, it was determined the Hospital failed to ensure sufficient staffing was provided to:
1. prevent patient care incidents
2.ensure appropriate nurse patient ratios in the Intensive Care Unit.

This deficient practice poses a risk to the health and safety of patients when there is not sufficient numbers and types of nursing personnel to meet the needs of the patient.

Cross reference: A-0043, A-0057, A-0286, A-0315, A-1110

Repeat citation from Event #WP5G11 07/12/2022

Findings include:

Policy titled, "Management of Staffing Resources (Acute Facilities)", revealed: "...Less than optimal: Deficit of staff members on a unit or in a department; based on staffing plan or anticipated units of service and anticipated acuity...The patient acuity score provides information to guide the nurse-patient assignment, aligning staff resources with patient care needs...Daily staffing is based on patient needs and the staffing and acuity plan...Staffing assignments are accomplished by maximizing available personnel to meet the needs of patients based on: a. patient acuity; b. patient census; c. availability of staff resources; d. staff competency and skill mix; e. hospital-wide needs...Arizona Adult Critical Care only: When the primary nurse is unable to give direct care to their patient due to a situation which may require the nurse to leave the ICU department, (i.e., diagnostic procedures, meal breaks, code arrest coverage, trauma call, etc.) Assignments may be adjusted as follows: i. the charge nurse or designee will designate another RN to temporarily assume responsibility of the patient, ii. the RN assuming temporary responsibility of ICU level patients may be responsible for 2 assigned patients plus one temporary reassigned patient...iv. Non-ICU level of care patients being care for in the ICU will have temporary coverage assigned as appropriate to the acuity of the patients but maintaining that any RN caring for ICU patients will not be responsible for more than 3 patients at a time on a temporary basis...."

The staffing acuity matrix was not provided by the facility.

Hospital document titled, "BBMC Event Log", revealed fourteen (14) patient falls between 01/17/2023 and 03/28/2023 that were accounted to "low staffing", "staffing below goal", "less than optimal staffing" or "staffing assignments busy with high acuity patients" as reasons for why fall occurred.

One (1) patient fall on 02/01/2023 was attributed to patient required a companion/sitter and one was not available.

One (1) patient fall on 03/07/2023 was attributed to not enough staff and "will add a companion when staffing allows."

One (1) patient fall on 03/11/2023 was attributed to "unsure why the bed alarm was not on. There were only 2 PCAs for 23 patients, 4 RNs so staffing was very busy. Charge nurse had 5 patients and this room."

Further review of the "BBMC Event Log" revealed on 03/07/2023 a patient was left unattended on a gurney with no call light in an unlit room in radiology. Further review of the incident revealed the patient had transfer orders from the ICU to Medical/Surgical 6th floor at time of transport to radiology for a radiology exam. Radiology department staff called for transport, were unaware that patient had not been picked up by transport. ICU staff and Medical Surgical staff unaware patient was unattended in radiology. "Units busy" was reason for the incident occurring.

Further review of the "BBMC Event Log" revealed two (2) patients developed wound care issues:

On 01/18/2023 it was discovered that one (1) patient's chest tube dressing had not been changed for five (5) days. Policy is that chest tube dressings are changed every 72 hours. The reason indicated for the chest tube dressing not being changed was "not enough staff".

One (1) patient on 03/21/2023 developed a hospital acquired pressure injury in the buttocks area due to urine soaked briefs not being changed when the patient soiled the briefs. The reason indicated on the log for how the incident occurred was "staff too busy with other patients."

Review of the "BBMC Event Log" revealed one (1) laboratory error in which a patient was on a heparin drip and coagulation factor lab was ordered to be drawn at 0830. The lab was not drawn until 1830. The reason for the missed lab work was the "nurse had five (5) patients and patient acuity and workload was high. Staffing was less than optimal this shift."

Further review of the "BBMC Event Log" revealed sixteen (16) patients that their telemetry monitors were off for one (1) to three (3) hours due to batteries needing to be changed. Further review of the incident log revealed the reason the telemetry monitor batteries were not changed in a timely manner "change of shift", "staff busy", "lack of staff".

Review of the Nursing Schedules/Staffing Assignments revealed that for each patient care unit, on most days each nurse had five (5) patients assigned. Each patient care tech was assigned twelve (12) to fourteen (14) patients. Several days a week, charge nurses were in ratio assigned one (1) to four (4) patients.

Review of the ICU Nursing Schedules/Staffing sheets revealed on these dates and shifts:
02/13/2023 day shift: one (1) nurse for rooms 212 and 213
02/13/2023 day shift: one (1) nurse for rooms 214 and 215
02/13/2023 day shift: one (1) nurse for rooms 218 and 220
02/13/2023 night shift: one (1) nurse for rooms 212, 215, 218
02/14/2023 day shift: one nurse for rooms 213 and 214
02/14/2023 day shift: one nurse for rooms 218 and 220
02/15/2023 day shift: one (1) nurse for rooms 221 and 222
02/15/2023 day shift: one (1) nurse for rooms 223 and 224
02/15/2023 night shift: one (1) nurse for rooms 221, 222, and 223
02/15/2023 night shift: one (1) nurse for rooms 224 and 225

Review of Emergency Department Activity Logs for January, February, and March revealed a delay in patient triage and medical screening examinations (MSE) being performed. Review of the following patients' medical records revealed the following arrival to MSE times:

Patient #10 was registered on 02/14/2023 at 2345, triaged at 0034 and a medical screening examination (MSE) was performed at 01:10. The arrival time to triage time was 49 minutes. The door to doctor time was 1 hour 25 minutes. Patient #10 was assigned an Emergency Severity Index (ESI) score of 2.

Patient #11 was registered on 1/10/2023 at 2355, triaged at 0044 and a MSE was performed at 0202. The arrival time to triage tme was 51 minutes. The door to doctor time was 2 hours and 7 minutes. Patient #11 was assigned an ESI of 3.

Patient #14 was registered on 01/06/2023 at 1627, triaged at 1631 and a MSE was performed at 2031. The arrival to triage time was 4 minutes. The door to doctor time was 4 hours and 4 minutes. Patient #14 was assigned an ESI of 2.

Patient #15 was registered on 01/04/2023 at 0726, triaged at 0740 and a MSE was performed at 1044. The arrival to triage time was 14 minutes. The door to doctor time was 3 hours and 18 minutes. Patient #15 was assigned an ESI of 3.

Patient #16 was registered on 03/13/2023 at 2338, triaged at 2340, and a MSE was performed at 0506. The arrival to triage time was 2 minutes. The door to doctor time was 5 hours and 28 minutes. Patient #16 was assigned an ESI of 3.

Observation on tour of the Emergency Department on 03/29/2023 revealed one (1) patient (Patient #4) lying on a stretcher in the hallway and the patient's family member sitting in a chair next to the gurney. Multiple empty rooms were observed at the time in the ED.

Employee #9 confirmed on 03/29/2023 that Patient #4 was receiving treatment in the ED hallway. Employee #9 confirmed that there were empty rooms available but the rooms were monitored rooms and they were reserved for potential incoming patients that required monitoring. Employee #9 stated Patient #4 did not require a monitored bed and there were only so many monitored beds in the zone Patient #4 was in. Employee #9 stated that Patient #4 could be moved to a different zone that had unmonitored beds but there was not enough staff to open another patient care zone.

Employee #9 confirmed on 03/29/2023 that delays in triage and medical screening examinations is due to lack of staffing and room availability, especially if the Emergency Department is holding patient admissions to inpatient units because the inpatient units do not have the staff to care for the patients.

Patient #4 and Patient #4 family representative confirmed on 03/29/2023 that staffing "does not appear to be sufficient". Patient #4 family representative confirmed that often s/he will have to assist Patient #4 with cares as staff are not available.

The family representative of Patient #7 confirmed during an interview conducted on 04/03/2023 that they have helped Patient #7 ambulate out of bed to use the toilet. Patient #7's family representative did not receive any guidance or instruction of how to ambulate Patient #7 out of the bed. Patient #7 is under fall precautions.

Employee #1 confirmed on 03/28/2023 that when a patient that is considered a fall risk and ambulates that a caregiver is to assist the patient.

Employee #1 confirmed on 03/29/2023 that staffing continues to be a struggle to fill empty staff positions. Employee #1 confirmed that the usual nurse patient ratio based on acuity is 1:5.

Employee #8 confirmed on 03/29/2023 that nurse patient assignments in the ICU are 1 to 1 or 1 to 2.

Based on review of policies and procedures, hospital documents, medical records, observations, and staff interviews, it was determined the Hospital failed to ensure nursing personnel followed policies and procedures when providing patient care to five (5) patients. This deficient practice poses a risk to the health and safety of patients when nursing staff do not implement proper care to patients.

Cross reference: A-0043, A-0057, A-0386, A-1110

Findings include:

Hospital policy titled, "Adult Patient Care", revealed: "...Purpose: Provide guidelines for the nursing assessment and care for adult patients throughout the care continuum...Vital Signs: Routine: ...Progressive/Intermediate Care: every 3-5 hours; Intensive Care: every 1-2 hours or per provider order...Excretion: Patients who are incontinent of stool, urine, and/or excessive vaginal discharge are considered at risk for skin breakdown and are assessed for the need for prophylactic intervention...Peri-care: daily, with each bowel movement, once per shift with indwelling urinary catheter...Oral hygiene: All patients 2 times per day...

Hospital policy titled, "Emergency Department Patient Care", revealed: "...Triage Assessment: Completed by a RN, Paramedic or QMP. If a Paramedic is used to expedite the triage to assist with high patient volume, the RN oversees the ESI scoring, care plan of the patient and utilizes standing orders when needed...An Emergency Severity Index (ESI) score is assigned when the triage assessment is completed. ESI 1= Requires immediate life-saving interventions; ESI 2= High risk situation or confused/lethargic/disoriented or severe pain distress; ESI 3= Two or more resources may be needed; ESI 4= One resource may be needed; ESI 5= No resources needed...Assessment/Reassessment: Occurs according to the patient's clinical presentation or any significant clinical event with the minimum requirements as follows:
· ESI 1= Continuous observation and monitoring, with documented reassessments at a minimum of every 1 hour until hemodynamically stable, then minimally every 2 hours or per admitting unit guidelines of care.
· ESI 2= Documented reassessments every 1 hour until hemodynamically stable, then minimally every 4 hours or per admitting unit guidelines of care.
· ESI 3= Documented every 4 hours
· ESI 4= Documented reassessments every 6 hours
· ESI 5= Documented reassessments every 6 hours
Reassessments may include, but are not limited to: Patient's current condition/status; Pain; Response to interventions...Vital signs to be completed at a minimum with every ED assessment/reassessment and within 60 minutes of patient disposition from ED. Vital signs include: heart rate, blood pressure, respiratory rate, temperature, oxygen saturation, pain, fetal heart tones (if applicable)...."

Hospital policy titled, "Left without Treatment (LWOT)", revealed: " ...Purpose: To ensure that hospital staff, physicians or Qualified Medical Personnel (QMP) utilize a standardized process that addresses a patient's decision to leave prior to completion of a Medical Screening Exam (MSE).To provide patients who request to Leave without Treatment (LWOT) with information about the risks associated with their decision ...Whenever possible, the support staff, nursing personnel, and/or the QMP is notified to allow an opportunity for the patient to receive information related to medical risks should they persist in leaving before their MSE and a discharge is completed ...If the patient is not seen leaving the facility, the nurse will document LWOT as the disposition in the patient's medical record ...If the patient is seen leaving or verbalizes to staff they are planning to leave before MSE, staff will attempt to encourage the patient to wait for the MSE. If the patient is unwilling to stay, staff will attempt to have the patient sign the LWOT form when treatment has not been completed ...If the patient/LAR (legally authorized representative) refuses to sign the Refusal of Examination form the following actions are taken: The patient's refusal to sign is documented on the form; Staff member who was present when the form was offered and refused will sign as witness to the refusal; Any known circumstances of the refusal are charted in the patient's record with a summary of the facts leading up to the refusal and what occurred at the time of refusal and, if applicable, that the QMP was notified ...."

Hospital policy titled, "Pain Management", revealed: "...Pain severity descriptors: mild, moderate and severe. Based on pain medication administration only. Mild pain: Pain is present but does not impair function (generally considered 1-3 on pain scale).Pain management is effective...Moderate pain: Pain is tolerable but causes significant discomfort and/or impairs function (generally 4-7 on pain scale). Pain management is partially effective. Needs intervention...Severe pain: Pain is intolerable, and the patient is unable to do anything because of pain (generally considered 8-10 on pain scale). Pain management is ineffective, needs urgent intervention...Ongoing assessment for the presence or absence of pain is completed by a clinician at a minimum of every shift or more often as patient condition warrants...The nurse assesses the patient's pain before and after giving an analgesic, and administers medication per provider order considering the following: a. Pain intensity, b. Pain Severity descriptors/function: i. Mild pain..., ii. Moderate pain...,iii. Severe pain...Reassess the patient after analgesic administration (opioid and non-opioid). This is a routine part of the ongoing pain assessment to identify any adverse side effects. A. Consider effect on function as well as pain severity/pain behaviors in the reassessment. b. If upon reassessment the patient's pain is not reduced, relieved, or at their desired acceptable pain intensity rating, implement additional interventions or contact the provider...

Patient #2
Patient #2 was admitted to the hospital from 03/10/2023 to 03/25/2023. Review of Patient #2 medical record revealed:
Oral care was not documented on the following dates and shifts:
03/12/2023 day shift
03/13/2023 day shift
03/14/2023 night shift
03/16/2023 day and night shifts
03/17/2023 night shift
03/18/2023 night shift
03/19/2023 day shift

Bed baths were documented on the following dates:
03/21/2023

Pericare was not documented on the following dates and shifts:
03/16/2023 day and night shift
03/18/2023 day and night shift
03/21/2023 day and night shift
03/22/2023 day and night shift
03/23/2023 day and night shift
03/24/2023 day and night shift

Changing of incontinent brief was not documented on the following dates and shifts:
03/11/2023 through 03/22/2023 both day and night shifts.

Review of Patient #2 pain assessment documentation revealed no pain assessment was documented from 03/10/2023 through 03/14/2023.

Review of Patient #2 medication administration record (MAR) revealed Patient #2 received pain medication as follows:
03/12/2023 1646: Fentanyl 50 mcg IV, no pain score was documented before administration and no reassessment was documented.
03/16/2023 1553: Fentanyl 50 mcg IV, no pain score was documented before administration, a reassessment score of "0" was documented at 1745.
03/21/2023 0206: Fentanyl 50 mcg IV, pain score "9", no reassessment was documented.
03/21/2023 0705: Fentanyl 50 mcg IV, no pain score documented, no reassessment documented.
03/21/2023 1509: Fentanyl 50 mcg IV, no pain score documented, reassessment at 1638 pain score "5".
03/21/2023 2144: Fentanyl 50 mcg IV, "10", reassessment at 2318 pain score "5".
03/22/2023 0242: Fentanyl 50 mcg IV, "9", no reassessment documented.
03/24/2023 0202: Fentanyl 50 mcg IV, no pain score documented, reassessment at 0249 pain score "3".
03/24/2023 0449: Fentanyl 50 mcg IV , no pain score documented, reassessment at 0620 pain score "4".
03/24/2023 1033: Fentanyl 50 mcg IV, "4", reassessment at 1103 pain score "4".
03/24/2023 1202: Fentanyl 50 mcg IV, "3", reassessment at 1457 pain score "3".
03/24/2023 1601: Fentanyl 50 mcg IV, "9", reassessment at 1810 pain score "3".
03/24/2023 2030: Fentanyl 50 mcg IV, "5", no reassessment documented.
03/24/2023 2146: Fentanyl 50 mcg IV, "9", reassessment at 2216 pain score "4"
03/25/2023 0101: Fentanyl 50 mcg IV, no pain score, reassessment at 0131 pain score "3".
03/25/2023 0258: Fentanyl 50 mcg IV, no pain score, reassessment at 0328 pain score "3".
03/25/2023 1043: Fentanyl 50 mcg IV, no pain score, reassessment at 1121 pain score "3".
03/25/2023 1404: Fentanyl 50 mcg IV , no pain score and no reassessment.
03/25/2023 1556: Fentanyl 50 mcg IV, no pain score, reassessment at 1710 pain score "3"
03/25/2023 1953: Fentanyl 50 mcg IV, no pain score or reassessment.

Further review of the medical record for Patient #2 revealed a pain score of "9" 03/22/2023 at 1005 was not addressed or treated. Further review revealed nursing staff administered pain medication ordered for severe pain for a pain score indicating mild or moderate pain. Further review revealed no documentation that nursing attempted to contact the medical provider to obtain orders for alternative pain medication for mild to moderate pain.

Further review of Patient #2 medical record revealed no nursing progress note was documented for the entire 15 day hospital stay.

Patient #11
Patient #11 was admitted to the Emergency Department (ED) on 01/10/2023 at 2355 and was discharged on 01/11/2023 at 0521. Patient #11 was assigned an ESI score of 3. Review of Patient #11 medical record revealed vital signs were performed at time of triage and at time of discharge. Further review of Patient #11 medical record revealed a pain assessment was conducted at time of triage and no further pain assessment was documented.

Patient #12
Patient #12 was admitted to the ED on 01/21/2023 at 0200. Review of Patient #12 medical record nurse note dated 01/21/2023 at 0307
revealed: "...Left without Treatment: Ambulated out of ED with steady gait." Further review of the medical record revealed no documentation that the staff attempted to dissuade Patient #12 from leaving the ED before the MSE could be performed. Further review of the medical record revealed no evidence that a Refusal of Treatment form had been completed by staff.

Patient #14
Patient #14 was admitted to the ED on 01/06/2023 at 1627 and triaged at 1631 with an assigned ESI of 2. Review of Patient #14 medical record revealed Patient #14 did not have any reassessments documented from 1631 until 2031. Patient #14 was admitted to the hospital inpatient unit on 01/07/2023 at 0853.

Patient #15
Patient #15 was admitted to the ED on 01/04/2023 at 0726 and assigned an ESI of 3 when triaged at 0740. Review of Patient #15 medical record revealed Patient #15 was admitted to the ED with a right femur fracture and urinary tract infection. Further review of the medical record revealed Patient #15 was not assessed for pain until 01/04/2023 at 2130.

Observation while on tour of hospital on 03/29/2023 revealed a performance improvement bulletin board in the hallway of the 4th floor patient care area. Observed on the board were the unit's performance improvement goals. One of the goals was oral care which revealed the goal was 90% and the current rate as of 03/29/2023 was 70.3%.

Employee #1 confirmed on 03/29/2023 that performance of patients' oral care needed improvement.

Employee #4 confirmed on 03/30/2023 that all patient activities of daily living such as bathing, oral hygiene, pericare are to be done per the guidelines in the Adult Care Policy for each individual unit.

Employee #5 confirmed on 04/03/2023 nursing staff will contact the medical provider to obtain medication orders for changes in patient conditions or pain.

Employee #25 confirmed on 04/03/2023 that pain level should be assessed every shift at a minimum. Employee #25 confirmed on 0/03/2023 that pain level should be documented when pain medication is administered, pain level should be reassessed 1-2 hours after pain medication administration and if no relief, treat the pain again or contact the medical provider depending on the medication order.

Employee #9 confirmed on 03/29/2023 that documentation of patient care needed improvement. Employee #9 confirmed that assessments and reassessments should be performed according to a patient's ESI score.

Based of review of policies and procedures, observations and staff interviews, it was determined the Hospital failed to ensure:

1. Staff followed isolation protocols with wearing personal protective equipment (PPE).
2. Staff were performing proper hand hygiene.
3. That patients rooms are cleaned daily

This deficient practice poses a risk to the health and safety of patients when staff do not follow isolation protocols or perform hand hygiene before and after patient care and patients rooms are not cleaned daily.

Cross reference: A-0043, A-0057, A-0386

Finding Include:
1.

Policy titled, "Standard and Transmission Based Precautions", revealed: "...Purpose: To prevent the transmission of pathogens n the healthcare settings...Contact transmission: The most common mode of transmission, contact transmission is divided into two subgroups: direct contact and indirect contact...Standard Precautions: Procedure
Hand washing and using gloves:
1. Wash or sanitize hands before and after contact with any patient/resident or items in the patient
environment. a. Alcohol-based hand rub may be used for routine hand hygiene except in the following instances:
i. When hands are visibly soiled. ii. During and after care of patients with suspect or confirmed C. difficile or other
spore forming pathogens, such as anthrax. In this case soap and water must be used for hand hygiene. iii. After using the restroom...2. Use only Banner approved soap or alcohol-based hand rubs...3. Wear clean, non-sterile gloves when touching blood, body fluids, excretions, secretions, mucous membranes, non-intact skin, and contaminated items or environmental surfaces...4. Remove gloves: a. Immediately after use. b. Before touching non-contaminated items and environmental surfaces. c. Before leaving patient room...Mask and Eye Protection: 1. Wear a mask with eye protection or a face shield to protect mucous membranes of the eyes, nose,and mouth: a. During procedures and patient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions (e.g., suctioning, bronchoscopy, intubation, procedures, arterial catheterization, wound irrigation, infant delivery, and autopsy). c. When providing direct face-to-face care for a productively coughing patient who cannot reliably
cover his/her cough...Using gowns: 1. Wear a gown to protect skin and prevent soiling or contamination of clothing during procedures or patient care activities that are expected to generate splashes or sprays of blood, body fluid,
secretions, and excretions. 2. Remove gown and perform hand hygiene before leaving patient's environment...Contact Precautions: Policy: 1. Staff implements Contact Precautions for all patients who are at potentially high risk for transmission of infection. 2. All HCW's perform hand hygiene and don gloves and gown prior to entering the patient room. 3. Patients that require Contact Precautions include, but are not limited to patients with: multi-drug resistant organisms (MDRO's) or other organisms of epidemiological significance, (e.g., MRSA, VRE, C. difficile, ESBL-producing bacteria, CRE-producing Enteric or other multi-resistant Enteric, multi-resistant Acinetobacter or Pseudomonas)...Patient Visitors: 1. Encourage patient visitors to follow Contact Precautions. Visitors to patients in Contact Precautions must check with the Registered Nurse for instructions in Contact Precautions before entering the room. If visitors are unable or unwilling to comply with Contact Precautions, they may be asked to leave. Visiting may be limited during periods when the risk of disease transmission is greatest. 2. Must perform hand hygiene upon entering and exiting the room...Patient environment: 1. Close or open door based on patient preference. 2. Obtain isolation supplies. 3. Place " Contact Precautions " sign on or near the door or in the caddy pocket. 4. Remove Contact Precautions sign ONLY after discharge cleaning has been completed by the
Environmental Services staff. 5. Use Contact Precautions (Special precautions) sign for patients on Contact Precautions for C. difficile. 6. Order equipment for dedicated use: Examples of dedicated equipment are: stethoscope, sphygmomanometer, B/P cuff, thermometer, commode, gait belt, 7. Clean and disinfect equipment with a Banner approved disinfectant immediately after use, if sharing of equipment is unavoidable. For example: blood glucose monitor, vital sign machine, scale, etc...Deliver water and ice to patient rooms in clean, disposable containers; do not take items such as water pitchers out of patient ' s room to the ice machine...Using PPE (personal protective equipment): 1. Perform hand hygiene prior to exit or immediately upon leaving patient environment. 2. Using PPE:
a. Perform hand hygiene, don clean gloves and gown prior to entering the room. b. Be vigilant about not contaminating the environment inside the room with gloved hands. c. Change gloves between different procedures on the same patient if blood or body fluids are encountered. d. Change gloves during patient care if the hands will move from a contaminated body-site (e.g.,wound, perineal area) to a clean body-site (face). e. Remove gloves and gown prior to leaving the patient's environment:
Dispose of gown in regular trash unless there are free flowing blood or body fluids on gown.
Do not touch, and ensure that clothing does contact, potentially contaminated surfaces in the environment...."

Observation while on tour of hospital patient care units conducted on 03/29/2023 and 04/03/2023 revealed multiple rooms on nursing care units with contact isolation signs posted on patient rooms.

Observation on 03/29/2023 and 04/03/2023 revealed both medical and nursing staff members entering isolation rooms without donning PPE.

Observation on 03/29/2023 and 04/03/2023 revealed both medical and nursing staff members exiting isolation rooms and failing to perform hand hygiene before beginning a new task or entering another patient room.

Observation conducted on 04/03/2023 during a hospital tour it was observed that a medical staff walked out of a room without personal protective equipment. The room was under isolation precautions.

Employee #1 confirmed during the tour conducted on 04/03/2023 that the room was under isolation precautions.

Employee #8 confirmed during an interview conducted on 03/29/2023 that staff are expected to following isolation protocols for the specific type of isolation posted on isolation rooms.

2.

Policy titled, "Hand Hygiene", revealed: "...III Policy: A. Hands must be washed or sanitized before and after contact with any patient or items in the patient environment ...C. Indications for hand washing and hand antisepsis: 2. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands, or wash hands with soap and water in the following clinical situations: a. Before having direct contact with patients ...d. After contact with a patient's intact skin ...e. After contact with body fluids or excretion, mucous membranes, non-intact skin, and wound dressing if hands are not visibly soiled ...."

Observation while on tour of the hospital patient care areas conducted on 03/29/2023 and 04/03/2023 revealed multiple medical and nursing staff members not performing proper hand hygiene before entering or after leaving patient rooms.

Observation on 03/29/2023 revealed staff members exiting a contact isolation room on the 7th floor and proceeded to enter another patient room without performing hand hygiene.

Observation in the fast track area of the Emergency Department on 03/29/2023 revealed a nursing staff member not performing hand hygiene before and after administering medication to a patient.

Observation on 04/03/2023 revealed a medical staff member exiting an isolation room and not performing hand hygiene before starting another task.

Employee #1 confirmed on 03/29/2023 that proper hand hygiene is to be performed by all staff. Employee #1 confirmed on 03/29/2023 that s/he was "not surprised" that staff were not performing hand hygiene.

3.

Policy titled, "EVS: Cleaning Patient Rooms and Treatment Areas", revealed: "...Performed by hospital EVS and Nursing staff...Patient care rooms are cleaned daily or according to the sensitivity of the location and at time of discharge...Nursing personnel are responsible for clearing the room of all:
" patient personal related items
" monitors
" medications
" body fluid containers
" patient related equipment, and
" removing waste from commodes...
Daily cleaning...work from cleanest to dirtiest..., empty waste basket and replace liner, disinfect the following: patient furniture (chairs, over bed table, bedside cabinet, bed siderails), door frames, IV poles and any cables/monitors that are in easy reach, sink and wipe sink top, bathroom, shower walls and door, mop the shower floor, toilet, spot clean walls, windows and baseboards, as needed, clean top and sides of television, if possible...replenish paper towels, toilet tissue, hand sanitizer, and soap, dust mop floor, wet mop floor...."

Observation while on tour of hospital conducted on 03/29/2023 and 04/03/2023 revealed the following on all patient care units of the hospital: multiple dirty food trays in patient rooms, multiple used styrofoam drink cups and empty medication cups on patient over bed tables and bedside cabinets. Further observation on tour revealed multiple patient rooms with dirty/soiled linens, bags of trash and dirt/debris on the floor of patient rooms. Further observation revealed empty, used IV medication bags remaining on IV poles.

Observation while on tour on 03/29/2023 revealed open drink containers and opened food packages were observed at a nursing charting area outside Rooms 210-211.

Employee #1 confirmed during an interview conducted on 03/29/2023 that patient rooms should be cleaned daily.

Based of review of policies and procedures, observations and staff interviews, it was determined the Hospital failed to ensure that the Emergency Department had sufficient staffing to ensure:

1.patients are triaged upon arrival to the Emergency Department (ED)
2.medical screening examinations are performed on patients in a timely manner.
3.patients are not treated for emergency conditions in the hallway.

This deficient practice poses a risk to the health and safety of patients when they are not triaged upon arrival and medical screening examinations are not done in a timely manner causing a delay in treatment and missing a life threatening condition.

Cross reference: A-0043, A-0057, A0315, A-0392, and A-1100

Findings Include:

Hospital policy titled, "EMTALA-Medical Screening Examination and Stabilization Treatment", revealed: "...Medical Screening Examination ("MSE"): An appropriate MSE will be offered to individuals on the Campus of Banner Hospitals with a Dedicated Emergency Department who request emergency medical services, on whose behalf such services are requested...When an EMS provider brings an individual to the Hospital with Dedicated Emergency Department and the Hospital does not have the capacity or capability to provide an immediate medical screening exam, and if needed, stabilizing or an appropriate transfer, the Hospital must still assess the individual upon arrival to ensure that the individual is appropriately prioritized based on presenting signs and symptoms. Hospital should assess whether the EMS can appropriately monitor the individual's condition...Triage establishes the order in which an individual will be evaluated and is not considered an emergency MSE...An MSE will be conducted to determine whether the Patient has an EMC (emergency medical condition)...The Hospital will conduct a consistent MSE, in nondiscriminatory matter, for all Patients with similar medical conditions...."

Hospital policy titled, "Emergency Department Patient Care", revealed: "...Triage Assessment: Completed by a RN, Paramedic or QMP. If a Paramedic is used to expedite the triage to assist with high patient volume, the RN oversees the ESI scoring, care plan of the patient and utilizes standing orders when needed...An Emergency Severity Index (ESI) score is assigned when the triage assessment is completed. ESI 1= Requires immediate life-saving interventions; ESI 2= High risk situation or confused/lethargic/disoriented or severe pain distress; ESI 3= Two or more resources may be needed; ESI 4= One resource may be needed; ESI 5= No resources needed...ED triage documentation may include, but is not limited to: Chief complaint, vital signs, pain, and oxygenation; Mode arrival and mechanisms of injury; Triage assessment and ESI scoring; Infectious Disease Screening; Suicide Screening...A medical screening exam (MSE) is completed by an Emergency Physician or QMP...When applicable, the ED Medical Provider and/or QMP will complete the MSE in conjunction with an RN or Paramedic as a joint assessment...Both the ED Medical Provider and/or QMP and RN or Paramedic perform a complaint specific assessment to prioritize, treat and evaluate for emergent, urgent, and non-urgent patients...Patient arriving from all portals of entry into the ED will receive a baseline assessment of their chief complaint by a registered nurse, physician or designee...An ESI score will be assigned based upon acuity and resources needed...Patients assigned ESI level 1 & 2 will be given placement priority...These priorities may be modified throughout the patient encounter as diagnostic testing/findings are made available and intervention/treatments are evaluated for effectiveness...."

Policy titled, "Management of Staffing Resources (Acute Facilities)", revealed: "...Less than optimal: Deficit of staff members on a unit or in a department; based on staffing plan or anticipated units of service and anticipated acuity...The patient acuity score provides information to guide the nurse-patient assignment, aligning staff resources with patient care needs...Daily staffing is based on patient needs and the staffing and acuity plan...Staffing assignments are accomplished by maximizing available personnel to meet the needs of patients based on: a. patient acuity; b. patient census; c. availability of staff resources; d. staff competency and skill mix; e. hospital-wide needs...Arizona Adult Critical Care only: When the primary nurse is unable to give direct care to their patient due to a situation which may require the nurse to leave the ICU department, (i.e., diagnostic procedures, meal breaks, code arrest coverage, trauma call, etc.) Assignments may be adjusted as follows: i. the charge nurse or designee will designate another RN to temporarily assume responsibility of the patient, ii. the RN assuming temporary responsibility of ICU level patients may be responsible for 2 assigned patients plus one temporary reassigned patient...iv. Non-ICU level of care patients being care for in the ICU will have temporary coverage assigned as appropriate to the acuity of the patients but maintaining that any RN caring for ICU patients will not be responsible for more than 3 patients at a time on a temporary basis...."

Review of Emergency Department Activity Logs for January, February, and March revealed a delay in patient triage and medical screening examinations (MSE) being performed. Review of the following patients' medical records revealed the following arrival to MSE times:

Patient #10 was registered on 02/14/2023 at 2345, triaged at 0034 and a medical screening examination (MSE) was performed at 01:10. The arrival time to triage time was 49 minutes. The door to doctor time was 1 hour 25 minutes. Patient #10 was assigned an Emergency Severity Index (ESI) score of 2.

Patient #11 was registered on 1/10/2023 at 2355, triaged at 0044 and a MSE was performed at 0202. The arrival time to triage tme was 51 minutes. The door to doctor time was 2 hours and 7 minutes. Patient #11 was assigned an ESI of 3.

Patient #14 was registered on 01/06/2023 at 1627, triaged at 1631 and a MSE was performed at 2031. The arrival to triage time was 4 minutes. The door to doctor time was 4 hours and 4 minutes. Patient #14 was assigned an ESI of 2.

Patient #15 was registered on 01/04/2023 at 0726, triaged at 0740 and a MSE was performed at 1044. The arrival to triage time was 14 minutes. The door to doctor time was 3 hours and 18 minutes. Patient #15 was assigned an ESI of 3.

Patient #16 was registered on 03/13/2023 at 2338, triaged at 2340, and a MSE was performed at 0506. The arrival to triage time was 2 minutes. The door to doctor time was 5 hours and 28 minutes. Patient #16 was assigned an ESI of 3.

Observation on tour of the Emergency Department on 03/29/2023 revealed one (1) patient (Patient #4) lying on a stretcher in the hallway and the patient's family member sitting in a chair next to the gurney. Multiple empty rooms were observed at the time in the ED.

Employee #9 confirmed on 03/29/2023 that Patient #4 was receiving treatment in the ED hallway. Employee #9 confirmed that there were empty rooms available but the rooms were monitored rooms and they were reserved for potential incoming patients that required monitoring. Employee #9 stated Patient #4 did not require a monitored bed and there were only so many monitored beds in the zone Patient #4 was in. Employee #9 stated that Patient #4 could be moved to a different zone that had unmonitored beds but there was not enough staff to open another patient care zone.

Employee #9 confirmed on 03/29/2023 that delays in triage and medical screening examinations is due to lack of staffing and room availability, especially if the Emergency Department is holding patient admissions to inpatient units because the inpatient units do not have the staff to care for the patients.