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Based on observation, record review and interview it was revealed the facility failed to provide timely assessments and safe care to patients arriving in the Emergency Department (ED). (See tag A 144). The facility also failed to provide adequate nursing personnel qualified in emergency care to meet the written emergency procedures and needs of the patients in the ED (See-1112). These failures have the potential for any patient seeking care in the ED, to have delayed careby unqualified staff that could result in pro-longed illness or death.

Based on record, interview and document review it was revealed the facility failed to follow their policy to triage all patients within five minutes of signing into the Emergency Room and to provide timely assessment and care to two (2) out of two (2) patients (See tag 0144--Care in a safe setting).

Findings include:

1. A review of clinical records revealed patient #1 had a diagnosis of severe symptomatic Peripheral Vascular Disease (PVD). She/he was registered in the Emergency Room (ER) 3/24/21 at 3:24 p.m. She/he was triaged at 4:59 p.m. and given a triage level of three (3). (A level three is "urgent") The ER log shows she/he left without being seen at 9:45 p.m. She/he returned to the ER 3/25/21 at 10:03 a.m. with the same diagnosis. She/he stated she/he was sent by Physician #1 for admission through the ER. She/he was triaged at 10:29 a.m. and again given a triage level of three (3). The staff did not reassess her/him between 10:30 a.m. and 4:19 p.m. Physician #2 ordered a Heparin bolus followed by a Heparin infusion at 8:47 p.m. Registered Nurse (RN) #1 did not give the Heparin bolus and start the infusion until 10:34 p.m.

2. A review of clinical records revealed patient #4 was had a diagnosis of Cerebrovascular Accident (CVA). She/he was registered in the ER 6/4/21 at 9:43 p.m. She/he stated she/he had been diagnosed with a brain mass on 5/24/21. She/he had experienced weakness of her extremities, but it acutely worsened on 6/4/21 at 8:00 a.m. She/he was triaged at 10:05 p.m. and given a triage level of three (3). At 10:28 p.m. staff called a stroke protocol for her/him. It was determined she/he had experienced a CVA.

3. An interview was conducted with an ER staff member on 6/7/21 at 3:20 p.m. She/he stated triage of ER patients should occur within five (5) to ten (10) minutes of registration.

4. An interview was conducted with an ER staff member on 6/8/21 at 9:40 a.m. She/he reviewed Patient #1 clinical record. She/he stated based on her triage level, Patient #1 should have been reassessed every two hours. She/he acknowledged this did not occur 3/25/21.

5. An interview was conducted with an ER staff member on 6/9/21 at 9:00 a.m. She/he stated RN #1 (who started the Heparin on Patient #1) was a contract nurse who oriented then worked in the ER four (4) days. She/he was a no-call no-show (did not call-off or show up for her registered shift) 4//6/21 and never returned to work. She/he was therefore unavailable for interview.

6. An interview was conducted with an ER staff member on 6/9/21 at 9:00 a.m. She/he stated RN #2 (who triaged Patient #4) was also a contract nurse. Her/his contract was up and her/his last day of work was 6/4/21. She/he was therefore unavailable for interview.

7. An interview was conducted with a pharmacy staff member on 6/8/21 at 1:40 p.m. She/he stated the Emergency Department uses a Pyxis system (a system used to track medication orders and provide nursing staff with immediate access to select medications). Heparin used for bolus and continuous intravenous drip are kept in the Pyxis.

8. Review of a document titled, "Triage in the Emergency Department" revised 6/17/20 revealed in part, "The triage nurse is responsible for reassessing patients in the Waiting Room after they have been triaged per triage level...If they are designated Urgent or Emergent, she/he will be reassessed by the triage nurse every hour while in the waiting room....In keeping with the standard of triage, within five (5) minutes of arrival when multiple patients sign in to be triaged, the primary nurse and CNM {Clinical Nurse Manager} may assist to triage."

Based on observation, interview and document review it was revealed the facility failed to ensure policies and procedures consistent with Centers for Disease Control (which the facility uses for guidelines) are in place.to properly prevent and/or contain the spread of COVID-19. (See tag A- 0749). They failed to provide screening for COVID-19 at facility entrances. (See tag A-0750).

Based on observation, interview and review of policy and procedures it was revealed the facility failed to ensure policies and procedures were enforced (screening) and failed to follow The Centers for Disease Control guidelines for signage for COVID-19, during a national pandemic. This failure places all patients at risk for infection and the community at harm for the spread of Covid-19.

Findings include:

1. On 6/7/21 at 10:20 a.m. a tour was conducted with the Infection Control Preventionist (ICP). The main entrance, the basement entrance (where some staff enter), the administrator entrance and the Emergency Room (ER) entrance were all unmonitored and there were no screeners for COVID-19. There were no signs on the entrances listing the signs and symptoms of COVID-19 or to refrain from entering the building if signs and symptoms were present. There were no signs to perform hand hygiene or maintain respiratory etiquette. Patients and visitors were noted sitting in the ER lobby. One person had their mask down below their nose. While the surveyor and ICP were talking in the lobby, a man entered the ER lobby and walked toward the outpatient hallway. He had no mask on and was eating. No personnel in the ED reminded him about the mask. The ICP followed him and reminded him of the rule.

2. An interview was conducted with the ICP 6/7/21 during the tour. The ICP stated, "There used to be signs in the main entrance lobby as required by the CDC (Centers for Disease Control), but they were removed. Sometime in early May they stopped screening all people who enter the building. She stated until May signs were up, and screening was done at all entrances per Centers for Disease Control guidelines and doesn't know why the screening was stopped and the signage removed."

3. Interviews were conducted with the Registered Nurses (RNs) working the fourth (4) floor 6/7/21 at 11:00 a.m. during the tour. RN #1 stated, I didn't know they were supposed to be screening visitors or instructing them on masks, hand hygiene, respiratory hygiene and restricting visits to the patient's rooms. She stated in part, "I didn't know we were supposed to be doing that." RN #2 stated she was not performing these tasks. She thought visitors were being screened at the entrance.

4. An interview was conducted with the ICP 6/7/21 at 1:15 p.m. and stated there was no policy and procedure for screening visitors, and "checked on" the signs which gave COVID-19 guidelines and instructions at the entrance. They were taken down to post updated signs. She told staff to get the signs up "now".

5. Observations were made 6/7/21 at 4:30 p.m. at the main entrance. There was no COVID-19 signage. Screening at the entrance was not being done.

6. Observations were made 6/8/21 at 12:25 p.m. with the ICP. The facility was not screening at either the main entrance or the ER entrance.

7. Observations were made 6/9/21 at 8:00 a.m. and at 11:40 a.m. The facility was not screening at the main entrance.

8. Review of a document titled, "ARH {Beckley Appalachian Regional Hospital} COVID 19 VISITATION GUIDELINES: 11/06/2020" reveals in part, "All visitors will be screened when entering an ARH facility. Any visitor with noted symptoms for the Covid 19 virus will not be allowed entry. All visitors should wash their hands with soap and water for 20 seconds or apply hand sanitizer when entering and leaving patient rooms. All visitors must stay in the patient's room the entire time of the visit."

9. Review of the CDC guidelines updated May 17, 2021 states in part, Screen and Triage Everyone Entering a Healthcare Facility for Signs and Symptoms of COVID-19: "Take steps to ensure that everyone adheres to source control measures and hand hygiene practices while in a healthcare facility. Post visual alerts (e.g., signs, posters) at the entrance and in strategic places (e.g., waiting areas, elevators, cafeterias) to provide instructions (in appropriate languages) about wearing a well-fitting form of source control and how and when to perform hand hygiene."

Based on Document review, medical record review and staff interview it was determined the facility failed to provide adequate staff to provide emergency care to meet the written emergency procedures and needs anticipated by the facility. This failure resulted in delay of care in two (2) out two (2) patients (patients #1 and #4). This failure creates the potential for harm to all Emergency Room patients.

Findings include:

1. Review of a document titled, "Triage in the Emergency Department," revised 6/17/20, revealed in part: "The triage nurse is responsible for reassessing patients in the Waiting Room after they have been triaged per triage level...If they are designated Urgent or Emergent, he/she will be reassessed by the triage nurse every hour while in the waiting room....In keeping with the standard of triage, within five (5) minutes of arrival when multiple patients sign in to be triaged, the primary nurse and CNM {Clinical Nurse Manager} may assist to triage."

2. A review of medical records revealed patient #1, registered in the Emergency Room (ER) on 3/24/21 at 3:24 p.m. and was triaged at 4:59 p.m. and given a triage level of three (3) urgent with a diagnosis of severe symptomatic Peripheral Vascular Disease (PVD). The ER log showed the patient left without being seen at 9:45 p.m. and returned to the ER on 3/25/21 at 10:03 a.m. with the same diagnosis. Patient #1, stated they were sent by Physician #1 for admission through the ER. The patient was triaged at 10:29 a.m. and again given a triage level of three (3) urgent. The ER staff did not reassess her between 10:30 a.m. and 4:19 p.m. Physician #2 ordered a Heparin bolus followed by a Heparin infusion at 8:47 p.m. Registered Nurse (RN) #1 did not give the Heparin bolus and the Heparin infusion was not started until 10:34 p.m.

3. A review of the medical record for patient #4, registered in the ER on 6/4/21 at 9:43 p.m. Patient #4, stated she had been diagnosed with a brain mass on 5/24/21 and was experiencing weakness of her extremities but it acutely worsened on 6/4/21 at 8:00 a.m. Patient #4,was triaged at 10:05 p.m. and given a triage level of three (3) urgent. At 10:28 p.m. staff called a stroke protocol for her. The physician diagnosed the patient with a Cerebral Vascular Accident (CVA).

4. An interview was conducted with the ER Nurse Manager (NM) on 6/7/21 at 3:20 p.m. ER NM stated triage of ER patients should occur within five (5) to ten (10) minutes of registration.

5. An interview was conducted with the ER NM on 6/8/21 at 9:40 a.m. The ER NM reviewed patient #1's clinical record. She stated based on her triage level, patient #1 should have been reassessed every two hours. She acknowledged this did not occur on 3/25/21.

6. An interview was conducted with the ER NM on 6/9/21 at 9:00 a.m. Stated RN #1 (who started the Heparin on patient #1) was a contract nurse who oriented then worked in the ER four (4) days. She was a no-call no-show (did not call-off or show up for her registered shift) on 4/6/21 and never returned to work. She was therefore unavailable for interview.

7. An interview was conducted with the ER NM on 6/9/21 at 9:00 a.m. Stated RN #2 (who triaged patient #4) was also a contract nurse. Her contract was up and her last day of work was 6/4/21. She was therefore unavailable for interview.

8. An interview was conducted with the ER Nurse Manager (NM) on 6/7/21 at 10:50 a.m. She stated the ER has twenty-four (24) beds, including two (2) trauma bays. She stated the facility has experienced a shortage of ER nurses and they have had a lot of turnover. As a result, they have been having trouble staffing all the ER beds. At the time of the interview fifteen (15) beds were staffed, all beds were full and there were patients in the waiting room. She stated they were on diversion "a lot recently" and the fourth (4th) floor was closed 3/25/21 due to the hospital's inability to staff the beds.

9. An interview was conducted with the Director of Pharmacy on 6/8/21 at 1:40 p.m. Stated the Emergency Department (ED) uses a Pyxis system (a system used to track medication orders and provide nursing staff with immediate access to select medications). Heparin used for bolus and continuous intravenous drip are kept in the Pyxis.