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Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The facility failed to follow its established protocol for the assessment, monitoring and treatment of a patient presenting to the Emergency Department (ED) with chest tightness and pain down both arms resulting in this patient becoming unresponsive in the facility's ED waiting room and then expiring in the cardiac catheterization lab; and the facility failed to ensure ED nursing staff performed measurements, monitoring, and treatment to a patient's anterior neck following the discovery of multiple abrasions made by the patient with a rusted razor blade.

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP3, EMP5, EMP6, EMP10, EMP11 and EMP12) regarding the survey team's concerns related to Patient Rights on October 29, 2021, at approximately 2:00 p.m.

Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting

Based on review of facility documents, medical records (MR) and staff interview (EMP), it was determined the facility failed to follow its established protocol for the assessment, monitoring and treatment of a patient presenting to the Emergency Department (ED) with chest tightness and pain down both arms for one of one applicable medical record reviewed (MR1), and the facility failed to ensure nursing staff performed measurements, monitoring and treatment to a patient's anterior neck following the discovery of multiple abrasions made by a rusted razor blade for one of one applicable medical records reviewed (MR12).

Findings include:

Review on October 29, 2021, of the facility's "Patient Rights and Responsibilities - Administrative" policy, last approved June 22, 2021, revealed "Scope: Lehigh Valley Health Network (LVHN) adopts this policy for the following selected licensed entities: ... Lehigh Valley Hospital - Pocono ... II. Policy: A. In accordance with The Commonwealth of Pennsylvania Department of Health's Rules and Regulations for hospitals (103.21), the Joint Commission standards and the CMS guidelines (Section 482.13), Lehigh Valley Health Network provides this policy, in support of patients' interests and well-being, and to establish the expectations for patients' responsibilities to the organization. ... IV. Procedure: A. LVHN recognizes that its hospitals have certain responsibilities to their patients which include: 1. Patient Rights ... (e.) Delivery of Care ... Patients have the right to receive emergency treatment without unnecessary delay ... Patients have the right to receive compassionate quality care at the highest professional level ..."

Review on October 29, 2021, of the facility's "Acute Coronary Syndrome Triage Policy," last reviewed May 29, 2019, revealed "Purpose Because the history of chest pain patients can be confusing and inexact, there needs to be a specific protocol that assists providers with a system to take the inconsistency out of these presentations. To that end, any patient 25 years and greater presenting with complaint of chest pain consistent with Acute Coronary Syndrome (ACS) or any patient 24 and under that presents with any signs and symptoms as described by the ACS Guidelines should follow the following protocol. Scope Emergency Room Nurse, Emergency Medical Technician Guidelines 1. Procedure /Responsibility/Action a. Protocol i. Patient should be taken directly to a treatment bed immediately on presentation to the greeter desk. The patient should be taken to the area via a wheelchair and placed on a cardiac monitor ... iii. Establish intravenous line with saline lock. ... v. Administer oxygen therapy at 2L/min via nasal cannula..."

Review on November 1, 2021, of the facility's "Documentation - Patient Care Services" policy, last approved July 27, 2021, revealed "I. Scope: Leigh Valley Health Network (LVHN) adopts this policy for the following selected licensed entities: ... Lehigh Valley Hospital - Pocono ... III. Purpose: The purpose of this document is to provide guidance for documenting clinical data utilizing [name of facility's computerized documentation program]. Clinical documentation of patient care will be completed in the interprofessional manner using electronic health record tools. The medical record is the legal record of the patient's hospital stay. Documentation in the medical record is specific to the patient's condition, reflects care given and provides information for communication among health care providers ...VII. Intervention/Guideline ... H. Notes Documentation 1. The majority of patient data will likely be documented within the flowsheet templates. Notes within the Notes activity will be used to document other pertinent information not captured in the flowsheets. ..."

1. Review of MR1 on October 29, 2021, at 10:30 a.m. revealed this patient presented to the facility's Emergency Department (ED) on October 26, 2021, at 1844, with the complaint of chest tightness beginning that day, radiating down both arms. The patient had a significant cardiac history of bypass surgery and placement of 14 stents.

Interview with EMP3 on October 29, 2021, at 10:45 a.m. confirmed MR1 presented to the facility's ED on October 26, 2021, at 1844, with the complaint of chest tightness beginning that day, radiating down both arms; and the patient had a significant cardiac history of bypass surgery and placement of 14 stents.

Review of MR1 on October 29, 2021, at 10:30 a.m. revealed physician orders were placed at 1901 instructing nursing staff to monitor MR1's vital signs and pulse oximetry; cardiac monitoring in the ED; a 12-lead ECG [electrocardiogram], oxygen at 2 liters/minute and to titrate for SATS (Saturation) <90 % and to insert an IV [intravenous line]. EMP2 acknowledged the physician's orders at 1901.

Interview with EMP1, EMP3, EMP5, EMP6 and EMP7 on October 29, 2021, at 10:30 a.m. confirmed MR1's documented physician orders were placed at 1901 instructing nursing staff to monitor MR1's vital signs and pulse oximetry; cardiac monitoring in the ED; a 12-lead ECG, oxygen at 2 liters/minute and to titrate for SATS (Saturation) <90 % and to insert an IV and that EMP2 acknowledged MR1's physician orders at 1901.
Interview with EMP1, EMP6 and EMP7 on October 29, 2021, at 11:15 a.m. revealed the facility's completed an investigation of this event on October 26, 2021. The investigation revealed MR1's family went to the ED triage desk and reported MR1 was beginning to have what was thought to be a seizure. EMP2 assessed MR1 at 1948 and determined this patient was in cardiac arrest. EMP2 called a Code and initiated CPR in front of patients in the ED waiting area. EMP1, EMP6 and EMP7 revealed facility staff then transported MR1 from the ED waiting area to the Trauma Bay in the ED. MR1 was placed on a cardiac monitor. EMP2 determined MR1 was in ventricular tachycardia (a type of abnormal heart rhythm when the lower chamber of the heart beats too fast to pump well and the body does not receive enough oxygenated blood) and ventricular fibrillation (a severely abnormal heart rhythm or uncontrolled twitching or quivering of the heart muscle causing blood not to pump from the heart and that is life threatening and sudden cardiac death occurs). EMP1, EMP6 and EMP7 revealed MR1 was then taken to the Cardiac Cath lab at 2105 on October 26, 2021, where this patient expired.

2. Review of MR12 on November 1, 2021, revealed this patient presented to the ED on October 19, 2021, for evaluation and treatment of suicidal and homicidal ideations and was admitted to the Behavioral Health Unit (BHU) in the ED. ED nursing staff assessed MR12 and determined this patient was not suicidal and did not require one-to-one monitoring. MR12 was allowed to go to the bathroom unattended. ED nursing documentation dated October 19, 2021, at 2149 revealed MR12 was noted to have multiple linear abrasions horizontally on the anterior neck when leaving the bathroom. There was no documentation in MR12 indicating nursing staff measured, treated, or monitored these multiple linear horizontal abrasions on this patient's anterior neck.

Interview with EMP5 on November 1, 2021, at approximately 11:20 a.m. confirmed MR12 presented to the ED on October 19, 2021, for evaluation and treatment of suicidal and homicidal ideations and was admitted to the BHU in the ED; ED nursing staff assessed MR12 and determined this patient was not suicidal and did not require one-to-one monitoring and MR12 was allowed to go to the bathroom unattended. EMP5 confirmed nursing documented on October 19, 2021, at 21:49 p.m. that MR12 was noted to have multiple linear abrasions horizontally on the anterior neck when leaving the bathroom and there was no documentation in MR12 indicating nursing staff measured, treated, or monitored these multiple linear horizontal abrasions on this patient's anterior neck. EMP5 confirmed measuring, providing treatment and monitoring of a patient's abrasions was basic nursing care.

Interview with EMP13 on November 1, 2021, at approximately 11:30 a.m. revealed MR12 used a rusted piece of razor blade to make the multiple linear abrasions horizontally to the anterior neck.

Cross reference
482.13 Patient Rights
482.23 (a) Organization Of Nursing Services
482.23 (b) Staffing And Delivery Of Care
482.23 (b)(2) Licensure Of Nursing Staff
482.23 (b)(3) RN Supervision of Nursing Care
482.23 (b)5) Patient Care Assignments
482.23 (b)(6) Supervision Of Contract Staff
482.55 (a)(2) Integration Of Emergency Services

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

The facility failed to ensure the Vice President of Patient Care Services assured adherence to regulatory requirements and patient safety standards. The facility was cited for deficient practice related to leaving chest pain patients in the Emergency Department waiting room for extended periods of time on August 17, 2021 and failed to correct the deficient practice. The facility also repeated deficiencies cited on December 10, 2020 and April 8, 2021, related to insufficient staffing. The facility failed to ensure agency nurse personnel files contained all required documentation. The facility failed to ensure Emergency Department registered nurses were competent to function in charge nurse and triage nurse assignments. The facility failed to provide adequate supervision of agency nurses in the Emergency Department.

The aforementioned deficient practices resulted in a patient who presented to the Emergency Department with chest pain and significant cardiac history arresting in the Emergency Department waiting area.

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP3, EMP5, EMP6, EMP10, EMP11 and EMP12) regarding the survey team's concerns related to Nursing Services on October 29, 2021, at approximately 2:00 p.m.

Cross reference
482.23 (a) Organization of Nursing Services
482.23 (b) Staffing and Delivery of Care
482.23 (b)(2) Licensure of Nursing Staff
482.23 (b)(3) RN Supervision of Nursing Care
482.23 (b)5) Patient Care Assignments
482.23 (b)(6) Supervision of Contract Staff
482.55 (a)(2) Integration of Emergency Services

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the Vice President of Patient Care Services assured adherence to regulatory requirements and patient safety standards.
Findings:
Review on October 29, 2021, of the facility job description "VP Patient Care Services" dated December 17, 2018, revealed "Job Summary: Serves as a member of the Extended Senior Management Council of Lehigh Valley Health Network (LVHN) with full authority, responsibility and accountability for the operational management of patient care services, at their assigned respective facility (LVH, LVH-M, LVH-H). Collaborates with the President of the assigned, respective entity. Provides visionary leadership to build and maintain a creative, innovative and cost effective environment, committed to continuous improvements in quality of service and customer satisfaction, provided in concert with LVHN's mission, vision and values. Provides oversight for the assigned respective entity's patient care services leaders, assuring accountability for network standards. The VP of Patient Care Services provides visionary leadership to build and maintain an environment which attracts and retains employees committed to continuous quality improvement, innovation, creative problem solving and the application of lean principles to achieve cost efficiencies in services provided. ... Special Skills Work requires demonstrated leadership abilities and qualities that reflect a thorough understanding of the needs and concerns of the nursing profession and clinical services. The VP of Patient Care Services will demonstrate: the ability to collaborate with senior entity leaders; the ability to motivate and inspire people to change as health care evolves and changes; the adeptness in building coalitions within their teams, network and the community. ... Performance Expectations ... Interprets and implements operating policies, procedures, and programs established by the Board and senior management staff. ... Position Standards 3. Monitors and evaluates patient care outcome measures which are compared to regional and national benchmarks. Performance Expectations 3.1 Assures standards of patient care for each clinical area of responsibility are developed, monitored, and improved if appropriate. Assures adherence to regulatory requirements and patient safety standards. ... 3.3 Establishes, maintains, and refines, as needed, mechanisms to assure continuous quality improvement activities. 3.4 Achieves designated customer satisfaction levels. Position Standards 4. Responsible for implementation and execution of patient care services short-and long-term goals, objectives, plans, processes, outcomes and budgets for the operational function of patient care services in the assigned respective entity. ... Position Standards 5. Maintains adequate and appropriate staff to ensure quality patient care services within a cost-effective environment. ... Performance Expectations ... 5.2 Establishes and continually monitors the methodologies used to determine the cost-effective allocation of human resources, including delivery systems and staff mix ratios. ... 5.4 Assures employee satisfaction, creating and sustaining environments which are professionally supportive and employee focused. ..."
Interview on November 1, 2021, with EMP7, at approximately 9:30 AM, confirmed EMP7 was responsible for the adherence to regulatory requirements and patient safety standards. EMP7 confirmed the facility was cited on December 10, 2020 and April 8, 2021, for insufficient nursing staff; and August 17, 2021, for failing to follow facility protocol for the treatment of patients with Acute Coronary Syndrome. EMP7 confirmed the facility failed to ensure deficient practice was not repeated.
Cross reference:
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 (b) Staffing And Delivery Of Care
482.23 (b)(2) Licensure Of Nursing Staff
482.23 (b)(3) RN Supervision of Nursing Care
482.23 (b)(5) Patient Care Assignments
482.23 (b)(6) Supervision Of Contract Staff
482.55 (a)(2) Integration Of Emergency Services

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to provide adequate staff in the Emergency Department as per facility policy for seven of seven assignment sheets reviewed.

Findings:

Review on November 1, 2021, of the facility policy "Staffing: Determining Need For And Seeking Replacement Staff - Patient Care Services," last reviewed December 2020, revealed "I. Scope: Lehigh Valley Health Network (LVHN) adopts this policy for the following selected licensed entities: ... Lehigh Valley Hospital - Pocono ... II. Policy: Each patient care unit is responsible to determine and meet unit staffing needs on a daily and shift basis. The unit's Director and Patient Care Coordinators (PCCs), Patient Care Managers (PCMs), Charge Nurse/Unit Leader/Supervisor collaborate in determining and meeting unit needs. In the absence of the Director, any of the aforementioned individuals perform this function independently. III. Purpose: Inform Patient Care Services of process to determine and meet staffing needs. ... V. Procedure: 1. The required staffing for the next shift is determined based on: a. Patient needs / level of care to include personal needs b. Unit staffing standards c. Unit census inclusive of blended levels of care d. Other relevant factors 2. The unit communicates any staffing needs and furlough situations to the Staffing Office/Supervisor minimum of two hours prior to the start of shift. 3. The unit Director, PCC/PCM or charge nurse identifies staffing needs and furlough situations. 4. Staffing Office/house supervisor communicates the feasibility of providing house wide resources to the unit. 5. If house wide resources are not available, additional staff time will be sought from the designated unit staff, considering: a. Per Diem b. Part time c. Full time d. Straight time e. Overtime f. Staff willingness to stay additional hours/come in early g. Staff willingness to adjust schedule (for a different day off) 6. If workload prohibits the Director from making necessary telephone calls, this task may be delegated to an Administrative Partner, unit designee (PCC/PCM), Supervisor, Staffing Office personnel or other individual. 7. Reassignment of staff from another patient care unit with available resources will occur based on reassignment policy. 8. If all reasonable efforts were made to obtain staffing resources and staffing needs are unable to be obtained to meet patient care needs, the Administrator is contacted to determine if existing circumstances require employees to be mandated to work extra time. ... "

Review on November 1, 2021, of the facility policy, "Staffing - Shift Allocation Of Nursing Resources - Patient Care Services," last reviewed December 2020, revealed ""I. Scope: Lehigh Valley Health Network (LVHN) adopts this policy for the following selected licensed entities: ... Lehigh Valley Hospital - Pocono ... II Key Points: 1. Prior to the beginning of each shift, unit specific scheduled staff is reviewed in conjunction with current patient census and established staffing recommendations. III. Purpose: Nursing Staff Office, Nursing Supervisors and Directors of patient care areas maintain adequate staffing to meet identified patient care needs on a daily/shift basis. ... VII. Intervention/Guideline: 1. Recommended staffing for each clinical care unit is established to define the staffing number and skill mix required per shift for patient type, identified census and the unit-specific method of patient care delivery. It is based on patient needs benchmarking data from units of similar specialty. Established recommendations will consider the number of qualified registered nurses required to: a. Deliver nursing care to those patients who require specific level of care; b. Coordinate the care of patients; and, c. Supervise and direct care provided to patients by other nursing staff members. 2. Prior to the beginning of each shift, unit specific scheduled staff is reviewed in conjunction with current patient census and established staffing recommendations. a. Variance from the established recommended staff due to sick calls, severe weather conditions, 1:1 care requirements, unit activity level or unusual patient care needs may necessitate adjusting staffing resources. 3. Adjustment of staffing resources shall occur utilizing the following allocation priorities: a. Scheduled float pool personnel; b. Procured additional float pool, per diem, or "extra hours" clinical care personnel; c. Reassigned unit-specific personnel with commensurate knowledge, competence and skills to meet defined patient care needs, and; d. Unit on-call staff. 4. Adjustment of staffing resources shall occur after communication with designated unit personnel and with attention to the Patient Care Manual document Staffing: Determine Need for and Seeking Replacement Staff. ... "

Review on November 1, 2021, of the facility policy, "Emergency Department (ED) Scope of Patient Care Services, last revised April 9, 2021, revealed "... I. Scope of Service A. Types of Patients Served: To provide a hospital plan for patients arriving in the Emergency Department with emergent needs that require immediate intervention and treatment. These services are available to the ED 24/7 and provide direct care to patients. B. Definitions: ESI: Emergency Severity Index: 'is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patient into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs (ESI, 2013).' C. Services, Treatments, Procedures, and Activities Performed: 1. Methods to assess and meet care needs are based on assessment in the triage and/or treatment area depending on the ESI assigned to the patient. ... 5. The hours of operation for the treatment area of the emergency department are 24/7. 6. Support services (availability, clinical necessity, timeliness of services, and whether provided directly through referral contracts). a. Support services for the emergency department include (but are not limited to): Radiology, Cardiac Services, Trauma Services, Diagnostic and Interventional Services. b. These services are available to the ED 24/7 and provide direct care to patients. c. Areas/Sites Where Services are Provided: Ground Floor, D-Wing consisting of 54 rooms. ... IV. Department Goals and Objectives: The Emergency Department is committed to providing comprehensive and efficient quality care to the patients of the community. ..."

Review on November 1, 2021, of the facility document "LVH - Pocono Nursing Staffing Matrix Guidelines," last revised January 2021, revealed the following grid:
"Nursing Unit ED
Level of Care Emergent Care
Registered Nurse: Patient Ratio ... 7am 6 RNs 9am 6 to 7 RNs 11am 8 RNs 3pm 10 RNs 7pm 10 RNs 9pm 10 RNs 11pm 6 RNs 3am 6 RNs ..."

Review on November 1, 2021, of the Emergency Department (ED) Assignment Sheet dated October 18, 2021, revealed there were eight registered nurses (RNs) scheduled at 7:00 p.m. and 9:00 p.m.

Interview on November 1, 2021, with EMP3, at approximately 12:00 p.m., confirmed there were eight RNs scheduled at 7:00 p.m. and 9:00 p.m. on October 18, 2021. EMP3 confirmed the ED did not meet the staffing matrix of 10 RNs.

Review on November 1, 2021, of the ED Assignment Sheet dated October 19, 2021, revealed there were nine RNs scheduled at 3:00 p.m., 7:00 p.m., and 9:00 p.m.

Interview on November 1, 2021, with EMP3, at approximately 12:05 p.m., confirmed there were nine RNs scheduled at 3:00 p.m., 7:00 p.m., and 9:00 p.m. on October 19, 2021. EMP3 confirmed the ED did not meet the staffing matrix of 10 RNs.

Review on November 1, 2021, of the ED Assignment Sheet dated October 20, 2021, revealed there were seven RNs scheduled at 11:00 a.m. and eight RNs scheduled at 3:00 p.m., 7:00 p.m., and 9:00 p.m.

Interview on November 1, 2021, with EMP3, at approximately 12:10 p.m., confirmed there were seven RNs scheduled at 11:00 a.m. and eight RNs scheduled at 3:00 p.m., 7:00 p.m., and 9:00 p.m. on October 20, 2021. EMP3 confirmed the ED did not meet the staffing matrix of 8 RNs at 11:00 a.m. and 10 RNs at 3:00 p.m., 7:00 p.m., and 9:00 p.m.

Continued review of the ED Assignment Sheet dated October 20, 2021, revealed at 3:00 AM the charge nurse was assigned to charge role, triage nurse, and behavioral health pod nurse.

Interview on November 1, 2021, with EMP3, at approximately 12:10 p.m., confirmed the charge nurse was assigned to three different positions at 3:00 a.m. on October 20, 2021.

Review on November 1, 2021, of the ED Assignment Sheet dated October 21, 2021, revealed there were nine RNs scheduled at 3:00 p.m.

Interview on November 1, 2021, with EMP3, at approximately 12:15 p.m., confirmed there were nine RNs working on October 21, 2021, at 3:00 p.m. EMP3 confirmed the ED did not meet the staffing matrix of 10 RNs at 3:00 p.m.

Continued review of the ED Assignment Sheet dated October 21, 2021, revealed at 9:00 a.m. the charge nurse was assigned to charge role, triage nurse, behavioral health pod nurse, and pod 6 nurse.

Interview on November 1, 2021, with EMP3, at approximately 12:15 p.m., confirmed the charge nurse was assigned to four different positions at 9:00 a.m. on October 21, 2021.

Continued review of the ED Assignment Sheet dated October 21, 2021, revealed at 11:00 p.m. the charge nurse was assigned to charge role, triage nurse, and behavioral health pod nurse.

Interview on November 1, 2021, with EMP3, at approximately 12:16 p.m., confirmed the charge nurse was assigned to three different positions at 11:00 p.m. on October 21, 2021.

Continued review of the ED Assignment Sheet dated October 21, 2021, revealed at 3:00 a.m. the charge nurse was assigned to charge role, triage nurse, behavioral health pod nurse, and pod 5 nurse.

Interview on November 1, 2021, with EMP3, at approximately 12:17 p.m., confirmed the charge nurse was assigned to four different positions at 3:00 a.m. on October 21, 2021.

Review on November 1, 2021, of the ED Assignment Sheet dated October 22, 2021, revealed eight RNs scheduled at 7:00 p.m. and 9:00 p.m. and five RNs scheduled at 3:00 a.m.

Interview on November 1, 2021, with EMP3, at approximately, 12:20 p.m. confirmed on October 22, 2021 there were eight RNs scheduled at 7:00 p.m. and 9:00 p.m. and five RNs scheduled at 3:00 a.m. EMP3 confirmed the ED did not meet the staffing matrix of 10 RNs at 7:00 p.m. and 9:00 p.m. and six RNs at 3:00 a.m.

Continued review of the ED Assignment Sheet dated October 22, 2021, revealed at 3:00 a.m. the charge nurse was assigned to charge role, triage nurse, behavioral health pod nurse.

Interview on November 1, 2021, with EMP3, at approximately 12:21 p.m., confirmed the charge nurse was assigned to three different positions at 3:00 a.m. on October 22, 2021.

Review on November 1, 2021, of the ED Assignment Sheet dated October 23, 2021, revealed five RNs scheduled at 7:00 a.m. and 9:00 a.m., six RNs scheduled at 11:00 a.m., seven RNs scheduled at 3:00 p.m., eight RNs scheduled at 7:00 p.m. and 9:00 p.m., and five RNs at 3:00 a.m.

Interview on November 1, 2021, with EMP3, at approximately, 12:25 p.m. confirmed on October 23, 2021 there were five RNs scheduled at 7:00 a.m. and 9:00 a.m., six RNs scheduled at 11:00 a.m., seven RNs scheduled at 3:00 p.m., eight RNs scheduled at 7:00 p.m. and 9:00 p.m., and five RNs at 3:00 a.m. EMP3 confirmed the ED did not meet the staffing matrix of six RNs at 7:00 a.m., six RNs at 9:00 a.m., eight RNs at 11:00 a.m., 10 RNs at 3:00 p.m., 7:00 p.m., and 9:00 p.m., and six RNs at 3:00 a.m.

Continued review of the ED Assignment Sheet dated October 23, 2021, revealed at 3:00 a.m. the charge nurse was assigned to charge role, triage nurse, and pod 1 nurse.

Interview on November 1, 2021, with EMP3, at approximately 12:28 p.m. confirmed the charge nurse was assigned to three different positions at 3:00 a.m. on October 23, 2021.

Review on November 1, 2021, of the ED Assignment Sheet dated October 26, 2021, revealed eight RNs scheduled at 7:00 p.m. and 9:00 p.m.

Interview on November 1, 2021, with EMP3, at approximately 12:30 p.m., confirmed on October 26, 2021, there were eight RNs scheduled at 7:00 p.m. and 9:00 p.m. EMP3 confirmed the ED did not meet the staffing matrix of 10 RNs at 7:00 p.m. and 9:00 p.m.

Continued review of the ED Assignment Sheet dated October 26, 2021, revealed at 11:00 p.m. and 3:00 a.m. the charge nurse was assigned to charge role, triage nurse, and behavioral health pod nurse.

Interview on November 1, 2021, with EMP3, at approximately 12:35 p.m., confirmed the charge nurse was assigned to three different positions at 11:00 p.m. and 3:00 a.m. on October 26, 2021.

Review on October 29, 2021, of MR1 revealed MR1 presented to the ED on October 26, 2021, at 6:44 p.m., with complaint of chest tightness beginning that day, radiating down both arms; had a significant cardiac history of bypass surgery in and placement of 14 stents.

Interview on October 29, 2021, with EMP3, at 10:45 a.m. confirmed MR1 presented to the ED on October 26, 2021, at 6:44 p.m., with complaint of chest tightness beginning that day, radiating down both arms; a significant cardiac history of bypass surgery in and placement of 14 stents.

Continued review of MR1 revealed physician orders placed at 7:01 p.m. instructing nursing staff to monitor MR1's vital signs and pulse oximetry; cardiac monitoring in the ED; a 12-lead ECG, oxygen at 2 liters/minute and to titrate for SATS (Saturation) <90 % and to insert an IV and EMP2 acknowledged MR1's physician orders.

Interview on October 29, 2021, with EMP1, EMP3, EMP5, EMP6, and EMP7, at 10:30 a.m. confirmed MR1's documented physician orders were placed at 7:01 p.m. instructing nursing staff to monitor MR1's vital signs and pulse oximetry; cardiac monitoring in the ED; a 12-lead ECG, oxygen at 2 liters/minute and to titrate for SATS (Saturation) <90 % and to insert an IV and that EMP2 acknowledged MR1's physician orders.

Interview on October 29, 2021, with EMP1, EMP6 and EMP7, at 11:15 a.m. revealed the facility's investigation of October 26, 2021, indicating MR1's family went to the ED triage desk and reported MR1 was beginning to have what was thought to be a seizure in the ED waiting area; EMP2 assessed MR1 at 7:48 p.m. and determined this patient was in cardiac arrest, EMP2 called a Code and initiated CPR in front of patients in the ED waiting area. EMP1, EMP6 and EMP7 confirmed facility staff then transported MR1 from the ED waiting area to the Trauma Bay in the ED and placed this patient on a cardiac monitor and that MR1 was in ventricular tachycardia (a type of abnormal heart rhythm when the lower chamber of the heart beats too fast to pump well and the body does not receive enough oxygenated blood) and ventricular fibrillation (a severely abnormal heart rhythm or uncontrolled twitching or quivering of the heart muscle causing blood not to pump from the heart and that is life threatening and sudden cardiac death occurs). EMP1, EMP6 and EMP7 revealed MR1 was taken to the Cardiac Cath lab at 9:05 p.m. on October 26, 2021, where MR1 expired.

Repeat deficiency cited on December 10, 2020 and April 8, 2021.

Cross reference:
482.13 Patient Rights
482.13 (c)(2) Patient Rights: Care in a Safe Setting
482.23 Nursing Services
482.23 (a) Organization of Nursing Services
482.55 Emergency Services
482.55 (a) Integration of Emergency Services

Based on review of facility documents, personnel files (PF), and staff interview (EMP), it was determined the facility failed to ensure agency nurse personnel files contained all required documentation for two of five personnel files reviewed (PF1 and PF3).

Findings:

Review on November 1, 2021, of the facility Agency Nurse Contract, dated December 3, 2020, revealed " ... Attachment 1A Clinical Subcontractor Staff Qualifications And Documentation ... 20 Pediatric Advanced Life Support (PALS) Prior to Assignment Start Date 20.1 Current card from America [sic] Heart Association require [sic] for all RNs or LPN/LVNs working in Pediatric Critical Care, Recovery, Emergency, or departments which provide moderate sedation. Required for all Respiratory Therapy staff (RRTs or CRTs). Client reserved the right to require for units not listed. ... 20.1.2 Name on certification must match name on driver's license. If name does not match, Name Affidavit must be completed by Subcontractor Staff and notarized. ... 26 FBI Fingerprint Clearance 60 days prior to Assignment Start Date 26.1 Clinical Subcontractor Staff for all Client Affiliates: FBI Fingerprint Clearance completed through Identego - Must have clearance within the past year to start - volunteer clearances will not suffice. See below for further instructions: 26.2 Fingerprint receipt obtained in the last 30 days are acceptable to start assignment. 26.3 FBI Fingerprint Original Results (& any attached forms) must be provided to the facility. ... "

Review on November 1, 2021, of PF1 revealed PF1 started at the facility as an agency registered nurse on March 22, 2021. There was no documentation of a current Pediatric Advanced Life Support.

Interview on November 1, 2021, with EMP6, at approximately 1:00 PM, confirmed PF1 did not contain documentation of a current Pediatric Advanced Life Support (PALS) at the time of review. EMP6 confirmed PF1 was an agency nurse working in the Emergency Department and PALS was required for all Emergency Department nurses.

Interview on November 1, 2021, with EMP3, at approximately 1:45 PM, confirmed PF1's PALS expired in September 2021 and PF1 continued to work in the Emergency Department from September to November 1, 2021.

Review on November 1, 2021, of PF2 revealed PF2 started at the facility as an agency registered nurse on April 5, 2021. There was no documentation of an FBI Fingerprint Clearance at the time of review.

Interview on November 1, 2021, with EMP6, at approximately 1:30 PM, confirmed PF2 did not contain documentation of an FBI Fingerprint Clearance. EMP6 confirmed PF2 worked in the Emergency Department and an FBI Fingerprint Clearance was required.

Interview on November 1, 2021, with EMP1, at approximately 2:00 PM, confirmed PF2 did not contain documentation of an FBI Fingerprint Clearance at the time of review.

Cross reference:
482.23 (a) Organization Of Nursing Services
482.23 (b)(6) Supervision Of Contract Staff

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure Emergency Department registered nurses evaluated and implemented actions to proactively resolve patient needs for one of one medical record reviewed (MR1).

Findings:

Review on November 1, 2021, of the facility job description "Registered Nurses," January 2021 revealed "... Job Summary Provides professional nursing care through skillful assessment, diagnosis, outcomes identification, planning, implementation, and evaluation in accordance with facility or department policies and procedures. Directs and manages the care of designated patients. Utilizes effective and appropriate communication styles. Assists in maintaining a safe work environment and maintains clinical and professional competency as appropriate to the population of patients served. Essential Functions Reflects the job's main responsibilities and is not intended to be an exhaustive list of all duties performed. The essential functions listed below and % of time may very between departments and locations, and are subject to change based on management discretion and organizational needs. Assesses, plans, implements, and evaluates the care for designated patients. Recognizes the need for and initiates collaboration/communication with physicians, interdisciplinary team members, and takes actions to proactively resolve patient needs. - Synthesizes available data, information, and knowledge relevant to the situation to make decisions which optimize patient outcomes based on ANA Scope and Standards of Practice and the Code of Ethics. ..."

Review on November 1, 2021, of the facility document "Registered Nurse Orientation Record," last revised January 2021, revealed "... Behavioral Expectations ... 1. Assesses, plans, implements and evaluates the care for designated patients. ... B. Reviews, evaluates, and as appropriate, revises the established plan of care for each patient every 8 hours 1. Intervenes to correct, minimize, or prevent actual or potential risks, based upon observation of physiological and/or behavioral data. ... ii. Initiates cardiac monitoring and demonstrates ongoing systematic analysis of cardiac rhythm ..."

Review on November 1, 2021, of the facility document, "Acute Coronary Syndrome Triage Policy," last reviewed May 29, 2019, revealed "Purpose Because the history of chest pain patients can be confusing and inexact, there needs to be a specific protocol that assists providers with a system to take the inconsistency out of these presentations. To that end, any patient 25 years and greater presenting with complaint of chest pain consistent with Acute Coronary Syndrome (ACS) or any patient 24 and under that presents with any signs and symptoms as described by the ACS Guidelines should follow the following protocol. Scope Emergency Room Nurse, Emergency Medical Technician Guidelines 1. Procedure /Responsibility/Action a. Protocol i. Patient should be taken directly to a treatment bed immediately on presentation to the greeter desk. The patient should be taken to the area via a wheelchair and placed on a cardiac monitor. ii. A 12-Lead EKG tracing should be completed and given to care provider for interpretation within 10 minutes. Document in patient care record EKG completion time, time EKG given to provider and provider will document time interpreted. iii. Establish intravenous line with saline lock. iv. Blood draw for CBC, PT/PTT, BMP and Troponin I at 0, 3 and 6 hours. V. Administer oxygen therapy at 2L/min via nasal cannula. vi. Portable CXR ..."

Review on October 29, 2021, of MR1 revealed MR1 presented to the ED on October 26, 2021, at 6:44 p.m., with the complaint of chest tightness beginning that day, radiating down both arms. The patient had a significant cardiac history of bypass surgery and placement of 14 stents. The patient was triaged at 6:57 p.m. and assessed as acuity level 2.

Interview on October 29, 2021, with EMP3, at 10:45 a.m. confirmed MR1 presented to the ED on October 26, 2021, at 6:44 p.m., with the complaint of chest tightness beginning that day, radiating down both arms. The patient had a significant cardiac history of bypass surgery and placement of 14 stents.

Interview on October 29, 2021, with EMP1, EMP6 and EMP7, at 11:15 a.m. revealed the facility's investigation of October 26, 2021, indicating MR1's family went to the ED triage desk and reported MR1 was beginning to have what was thought to be a seizure in the ED waiting area; EMP2 assessed MR1 at 7:48 p.m. and determined this patient was in cardiac arrest, EMP2 called a Code and initiated CPR in the ED waiting area. EMP1, EMP6 and EMP7 confirmed facility staff then transported MR1 from the ED waiting area to the Trauma Bay in the ED and placed this patient on a cardiac monitor and that MR1 was in ventricular tachycardia (a type of abnormal heart rhythm when the lower chamber of the heart beats too fast to pump well and the body does not receive enough oxygenated blood) and ventricular fibrillation (a severely abnormal heart rhythm or uncontrolled twitching or quivering of the heart muscle causing blood not to pump from the heart and that is life threatening and sudden cardiac death occurs). EMP1, EMP6 and EMP7 revealed MR1 was taken to the Cardiac Cath lab at 9:05 p.m. on October 26, 2021, where MR1 expired.

Review on November 1, 2021, of PF3 revealed PF3 completed the facility ED Registered Nurse Orientation Record.

Interview on November 1, 2021, with EMP3, at approximately 2:00 p.m. confirmed PF3 completed the facility ED Registered Nurse Orientation Record. EMP3 confirmed PF3 was oriented to facility policies and procedures. EMP3 confirmed PF3 did not immediately bed MR1 and did not initiate continuous cardiac monitoring upon presentation.

Cross reference:
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 (a) Organization Of Nursing Services
482.23 (b) Staffing And Delivery Of Care
482.23 (b)(2) Licensure Of Nursing Staff
482.23 (b)5) Patient Care Assignments
482.23 (b)(6) Supervision Of Contract Staff
482.55 (a)(2) Integration Of Emergency Services

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure Emergency Department registered nurses were determined competent to function in the triage nurse and charge nurse roles for two of two personnel files reviewed (PF1 and PF3).

Findings:

A request was made for the facility Emergency Department (ED) Charge Nurse Job Description on November 1, 2021. None was provided.

A request was made for the facility Emergency Department (ED) Triage Nurse Job Description on November 1, 2021. None was provided.

Interview on November 1, 2021, with EMP12, at approximately 12:00 p.m., revealed the facility did not have specific ED Charge Nurse or ED Triage Nurse job descriptions. EMP12 revealed the facility did not have an ED registered nurse job description. EMP12 revealed the facility had one general registered nurse job description and unit specific orientation records.

Review on November 1, 2021, of the facility job description, "Registered Nurses," January 2021 revealed "... Job Summary Provides professional nursing care through skillful assessment, diagnosis, outcomes identification, planning, implementation, and evaluation in accordance with facility or department policies and procedures. Directs and manages the care of designated patients. Utilizes effective and appropriate communication styles. Assists in maintaining a safe work environment and maintains clinical and professional competency as appropriate to the population of patients served. Essential Functions Reflects the job's main responsibilities and is not intended to be an exhaustive list of all duties performed. The essential functions listed below and % of time may very between departments and locations, and are subject to change based on management discretion and organizational needs. Assesses, plans, implements, and evaluates the care for designated patients. Recognizes the need for and initiates collaboration/communication with physicians, interdisciplinary team members, and takes actions to proactively resolve patient needs. - Synthesizes available data, information, and knowledge relevant to the situation to make decisions which optimize patient outcomes based on ANA Scope and Standards of Practice and the Code of Ethics. Demonstrates commitment to quality and safety, in accordance with established policies and procedures, utilizing evidence-based practice. Participates in evidenced-based practice and research projects as applicable. Uses effective and appropriate verbal and non-verbal communication styles with patients, significant others, visitors, staff, and professional colleagues. Coordinates and provides patient and family education throughout treatment course to facilitate and effective transition of care. Functions as a department team member to support unit and hospital goals and objectives. Participates in all phases of the performance improvement process, including organization and unit-based patient experience goals. Performs validated technical skills based upon clinical specialty and unit practice. Utilizes technology and incorporates technology to optimize alternative modes of care delivery. Demonstrates leadership and team building skills including: - Teaching and mentoring new colleagues and department interns. Additional precepting, as assigned. - Delegating on the basis of skills and expertise of team member, acuity and specific needs of the patient, and time availability of team members. -Providing input as requested for performance appraisals of care delivery team members. ..."

Review on November 1, 2021, of the facility document, "Registered Nurse Orientation Record," last revised January 2021, revealed "... Behavioral Expectations ... 1. Assesses, plans, implements and evaluates the care for designated patients. ... B. Reviews, evaluates, and as appropriate, revises the established plan of care for each patient every 8 hours 1. Intervenes to correct, minimize, or prevent actual or potential risks, based upon observation of physiological and/or behavioral data. ... ii. Initiates cardiac monitoring and demonstrates ongoing systematic analysis of cardiac rhythm ..."

Interview on November 1, 2021, with EMP3, at approximately 12:15 p.m. confirmed the Registered Nurse Orientation Record was the orientation record for ED registered nurses. EMP3 confirmed there was no documentation regarding triage nurse or charge nurse roles and responsibilities. EMP3 confirmed there was no documentation ED nurses were trained and competent in charge and triage nurse roles.

Review on November 1, 2021, of PF1 and PF3 revealed there was no documentation PF1 and PF3 were determined competent to perform triage nurse and charge nurse roles.

Review on October 29, 2021, of MR1 revealed MR1 presented to the ED on October 26, 2021, at 6:44 p.m., with the complaint of chest tightness beginning that day, radiating down both arms. The patient had a significant cardiac history of bypass surgery and placement of 14 stents. There was documentation MR1 was triaged at 6:57 p.m. and assessed as acuity level 2.

Interview on October 29, 2021, with EMP3, at 10:45 a.m. confirmed MR1 presented to the ED on October 26, 2021, at 6:44 p.m., with the complaint of chest tightness beginning that day, radiating down both arms, and the patent had a significant cardiac history of bypass surgery and placement of 14 stents.

Interview on October 29, 2021, with EMP1, EMP6 and EMP7, at 11:15 a.m. revealed the facility's investigation of October 26, 2021, indicating MR1's family went to the ED triage desk and reported MR1 was beginning to have what was thought to be a seizure in the ED waiting area; EMP2 assessed MR1 at 7:48 p.m. and determined this patient was in cardiac arrest, EMP2 called a Code and initiated CPR in the ED waiting area. EMP1, EMP6 and EMP7 confirmed facility staff then transported MR1 from the ED waiting area to the Trauma Bay in the ED and placed this patient on a cardiac monitor and that MR1 was in ventricular tachycardia (a type of abnormal heart rhythm when the lower chamber of the heart beats too fast to pump well and the body does not receive enough oxygenated blood) and ventricular fibrillation (a severely abnormal heart rhythm or uncontrolled twitching or quivering of the heart muscle causing blood not to pump from the heart and that is life threatening and sudden cardiac death occurs). EMP1, EMP6 and EMP7 revealed MR1 was taken to the Cardiac Cath lab at 9:05 p.m. on October 26, 2021, where MR1 expired.

Review on November 1, 2021, of PF3 revealed PF3 completed the facility ED Registered Nurse Orientation Record.

Interview on November 1, 2021, with EMP3, confirmed PF3 completed the facility ED Registered Nurse Orientation Record. EMP3 confirmed PF3 was oriented to facility policies and procedures. EMP3 confirmed PF3 did not immediately bed MR1 and did not initiate continuous cardiac monitoring upon presentation per facility policy. EMP3 confirmed PF1 was the charge nurse on October 26, 2021, from 11:00 a.m. to 7:00 p.m.. EMP3 revealed it was the charge nurse's responsibility to facilitate patient flow in the ED.

Cross reference:
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 (a) Organization of Nursing Services
482.23 (b) Staffing and Delivery of Care
482.23 (b)(2) Licensure of Nursing Staff
482.23 (b)(3) RN Supervision of Nursing Care
482.23 (b)(6) Supervision of Contract Staff
482.55 (a)(2) Integration of Emergency Services

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure oversight of agency registered nurses in the Emergency Department for five of seven assignment sheets reviewed.

Findings:

Review on October 29, 2021, of the facility job description "VP Patient Care Services" dated December 17, 2018, revealed "Job Summary: Serves as a member of the Extended Senior Management Council of Lehigh Valley Health Network (LVHN) with full authority, responsibility and accountability for the operational management of patient care services, at their assigned respective facility (LVH, LVH-M, LVH-H). Collaborates with the President of the assigned, respective entity. Provides visionary leadership to build and maintain a creative, innovative and cost effective environment, committed to continuous improvements in quality of service and customer satisfaction, provided in concert with LVHN's mission, vision and values. Provides oversight for the assigned respective entity's patient care services leaders, assuring accountability for network standards. The VP of Patient Care Services provides visionary leadership to build and maintain an environment which attracts and retains employees committed to continuous quality improvement, innovation, creative problem solving and the application of lean principles to achieve cost efficiencies in services provided. ... Special Skills Work requires demonstrated leadership abilities and qualities that reflect a thorough understanding of the needs and concerns of the nursing profession and clinical services. The VP of Patient Care Services will demonstrate: the ability to collaborate with senior entity leaders; the ability to motivate and inspire people to change as health care evolves and changes; the adeptness in building coalitions within their teams, network and the community. ... Performance Expectations ... Interprets and implements operating policies, procedures, and programs established by the Board and senior management staff. Position Standards 3. Monitors and evaluates patient care outcome measures which are compared to regional and national benchmarks. Performance Expectations Assures standards of patient care for each clinical area of responsibility are developed, monitored, and improved if appropriate. Assures adherence to regulatory requirements and patient safety standards. ... 3.3 Establishes, maintains, and refines, as needed, mechanisms to assure continuous quality improvement activities. 3.4 Achieves designated customer satisfaction levels. Position Standards 4. Responsible for implementation and execution of patient care services short-and long-term goals, objectives, plans, processes, outcomes and budgets for the operational function of patient care services in the assigned respective entity. ... Position Standards 5. Maintains adequate and appropriate staff to ensure quality patient care services within a cost-effective environment. ... Performance Expectations ... 5.2 Establishes and continually monitors the methodologies used to determine the cost-effective allocation of human resources, including delivery systems and staff mix ratios. ... 5.4 Assures employee satisfaction, creating and sustaining environments which are professionally supportive and employee focused. ..."

Interview on November 1, 2021, with EMP7, at approximately 9:30 a.m., confirmed EMP7 was responsible for the adherence to regulatory requirements and patient safety standards. EMP7 confirmed their overall responsibility for nursing services including agency and travel nurse personnel.

A request was made for the facility Emergency Department (ED) Charge Nurse Job Description on November 1, 2021. None was provided.

Interview on November 1, 2021, with EMP12, at approximately 12:00 p.m., revealed the facility did not have specific ED Charge Nurse job description. EMP12 revealed the facility did not have an ED registered nurse job description.

Review on November 1, 2021, of the facility policy "Staffing: Determining Need For And Seeking Replacement Staff - Patient Care Services," last reviewed December 2020, revealed ""I. Scope: Lehigh Valley Health Network (LVHN) adopts this policy for the following selected licensed entities: ... Lehigh Valley Hospital - Pocono ... II. Policy: Each patient care unit is responsible to determine and meet unit staffing needs on a daily and shift basis. The unit's Director and Patient Care Coordinators (PCCs), Patient Care Managers (PCMs), Charge Nurse/Unit Leader/Supervisor collaborate in determining and meeting unit needs. In the absence of the Director, any of the aforementioned individuals perform this function independently. III. Purpose: Inform Patient Care Services of process to determine and meet staffing needs. ... V. Procedure: 1. The required staffing for the next shift is determined based on: a. Patient needs / level of care to include personal needs b. Unit staffing standards c. Unit census inclusive of blended levels of care d. Other relevant factors 2. The unit communicates any staffing needs and furlough situations to the Staffing Office/Supervisor minimum of two hours prior to the start of shift. 3. The unit Director, PCC/PCM or charge nurse identifies staffing needs and furlough situations. 4. Staffing Office/house supervisor communicates the feasibility of providing house wide resources to the unit. 5. If house wide resources are not available, additional staff time will be sought from the designated unit staff, considering: a. Per Diem b. Part time c. Full time d. Straight time e. Overtime f. Staff willingness to stay additional hours/come in early g. Staff willingness to adjust schedule (for a different day off) 6. If workload prohibits the Director from making necessary telephone calls, this task may be delegated to an Administrative Partner, unit designee (PCC/PCM), Supervisor, Staffing Office personnel or other individual. 7. Reassignment of staff from another patient care unit with available resources will occur based on reassignment policy. 8. If all reasonable efforts were made to obtain staffing resources and staffing needs are unable to be obtained to meet patient care needs, the Administrator is contacted to determine if existing circumstances require employees to be mandated to work extra time. ... "

Review on November 1, 2021, of the facility policy, "Staffing - Shift Allocation Of Nursing Resources - Patient Care Services," last reviewed December 2020, revealed ""I. Scope: Lehigh Valley Health Network (LVHN) adopts this policy for the following selected licensed entities: ... Lehigh Valley Hospital - Pocono ... II Key Points: 1. Prior to the beginning of each shift, unit specific scheduled staff is reviewed in conjunction with current patient census and established staffing recommendations. III. Purpose: Nursing Staff Office, Nursing Supervisors and Directors of patient care areas maintain adequate staffing to meet identified patient care needs on a daily/shift basis. ... VII. Intervention/Guideline: 1. Recommended staffing for each clinical care unit is established to define the staffing number and skill mix required per shift for patient type, identified census and the unit-specific method of patient care delivery. It is based on patient needs benchmarking data from units of similar specialty. Established recommendations will consider the number of qualified registered nurses required to: a. Deliver nursing care to those patients who require specific level of care; b. Coordinate the care of patients; and, c. Supervise and direct care provided to patients by other nursing staff members. 2. Prior to the beginning of each shift, unit specific scheduled staff is reviewed in conjunction with current patient census and established staffing recommendations. a. Variance from the established recommended staff due to sick calls, severe weather conditions, 1:1 care requirements, unit activity level or unusual patient care needs may necessitate adjusting staffing resources. 3. Adjustment of staffing resources shall occur utilizing the following allocation priorities: a. Scheduled float pool personnel; b. Procured additional float pool, per diem, or "extra hours" clinical care personnel; c. Reassigned unit-specific personnel with commensurate knowledge, competence and skills to meet defined patient care needs, and; d. Unit on-call staff. 4. Adjustment of staffing resources shall occur after communication with designated unit personnel and with attention to the Patient Care Manual document Staffing: Determine Need for and Seeking Replacement Staff. ... "

Review on November 1, 2021, of the Emergency Department (ED) Assignment Sheet dated October 18, 2021, revealed an agency nurse was in charge of the ED from 3:00 p.m. to 7:00 p.m.

Interview on November 1, 2021, with EMP3, at approximately 12:00 p.m., confirmed there was an agency nurse was in charge of the ED from 3:00 p.m. to 7:00 p.m on October 18, 2021.

Review on November 1, 2021, of the ED Assignment Sheet dated October 19, 2021, revealed an agency nurse was in charge of the ED from 7:00 a.m. to 7:00 p.m.

Interview on November 1, 2021, with EMP3, at approximately 12:05 p.m., confirmed there was an agency nurse was in charge of the ED from 7:00 a.m. to 7:00 p.m. on October 19, 2021.

Review on November 1, 2021, of the ED Assignment Sheet dated October 20, 2021, revealed an agency nurse was in charge of the ED from 7:00 a.m. to 7:00 p.m.

Interview on November 1, 2021, with EMP3, at approximately 12:10 p.m., confirmed there was an agency nurse was in charge of the ED from 7:00 a.m. to 7:00 p.m. on October 20, 2021.

Review on November 1, 2021, of the ED Assignment Sheet dated October 21, 2021, revealed an agency nurse was in charge of the ED from 11:00 a.m. to 7:00 p.m.

Interview on November 1, 2021, with EMP3, at approximately 12:15 p.m., confirmed there was an agency nurse was in charge of the ED from 11:00 a.m. to 7:00 p.m. on October 21, 2021.

Review on November 1, 2021, of the ED Assignment Sheet dated October 26, 2021, revealed an agency nurse was in charge of the ED from 11:00 a.m. to 7:00 p.m.

Interview on November 1, 2021, with EMP3, at approximately 12:20 p.m., confirmed there was an agency nurse was in charge of the ED from 11:00 a.m. to 7:00 p.m. on October 26, 2021.

Cross reference:
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 (a) Organization Of Nursing Services
482.23 (b) Staffing And Delivery Of Care
482.23 (b)(2) Licensure Of Nursing Staff
482.23 (b)(3) RN Supervision of Nursing Care
482.23 (b)5) Patient Care Assignments
482.55 (a)(2) Integration Of Emergency Services

Based on the seriousness of the non-compliance and the effect on patient outcome, the facility failed to substantially comply with this condition.

Findings include:

The information reviewed during the survey provided evidence the facility failed to follow its established protocol for the treatment of patients presenting to the Emergency Department (ED).

The ED Triage Nurse documented the patient presented to the ED with a complaint of chest tightness radiating down both arms. The patient had a significant cardiac history of bypass surgery and placement of 14 stents. It was determined this patient met the Triage level of 2. The patient was returned to the ED waiting room. The patient coded while in the waiting room, was taken to the Trauma Bay, was found to be in ventricular tachycardia and ventricular fibrillation when connected to a cardiac monitor, and was taken to the cardiac cath lab where the patient expired.

The facility failed to ensure a patient presenting to the Emergency Department (ED) with chest tightness was taken directly to a treatment bed immediately on presentation to the greeter desk. The facility failed to ensure this patient was placed on a cardiac monitor. The facility failed to ensure an intravenous line was started. The facility failed to ensure this patient was administered oxygen therapy at 2 L/m via nasal cannula.

A discussion took place with the survey team and the facility's administrative staff (EMP1, EMP3, EMP5, EMP6, EMP10, EMP11 and EMP12) regarding the survey team's concerns related to Patient Rights on October 29, 2021, at approximately 2:00 p.m.

Cross reference
482.55 (a)(2) Integration of Emergency Services

Based on review of facility documents, medical record (MR) and staff interview (EMP), it was determined the facility failed to ensure a patient presenting to the Emergency Department (ED) with chest tightness was taken directly to a treatment bed immediately on presentation to the greeter desk for one of one applicable medical record reviewed (MR1); the facility failed to ensure a patient presenting to the ED with chest tightness was placed on a cardiac monitor for one of one applicable medical record reviewed (MR1); the facility failed to ensure a patient presenting to the ED with chest tightness had an intravenous line started for one of one applicable medical record reviewed (MR1) and the facility failed to ensure a patient presenting to the ED with chest tightness was administered oxygen therapy at 2 L/m via nasal cannula for one of one applicable medical record reviewed (MR1).

Findings include:

Review on October 29, 2021, of the facility's "Acute Coronary Syndrome Triage Policy," last reviewed May 29, 2019, revealed "Purpose Because the history of chest pain patients can be confusing and inexact, there needs to be a specific protocol that assists providers with a system to take the inconsistency out of these presentations. To that end, any patient 25 years and greater presenting with complaint of chest pain consistent with Acute Coronary Syndrome (ACS) or any patient 24 and under that presents with any signs and symptoms as described by the ACS Guidelines should follow the following protocol. Scope Emergency Room Nurse, Emergency Medical Technician Guidelines 1. Procedure /Responsibility/Action a. Protocol i. Patient should be taken directly to a treatment bed immediately on presentation to the greeter desk. The patient should be taken to the area via a wheelchair and placed on a cardiac monitor. ii. A 12-Lead EKG tracing should be completed and given to care provider for interpretation within 10 minutes. Document in patient care record EKG completion time, time EKG given to provider and provider will document time interpreted. iii. Establish intravenous line with saline lock. iv. Blood draw for CBC, PT/PTT, BMP and Troponin I at 0, 3 and 6 hours. V. Administer oxygen therapy at 2L/min via nasal cannula. vi. Portable CXR ..."

Review on October 29, 2021, of the facility's "Triage System For The Emergency Department - Emergency Medicine" policy, last approved January 21, 2020, revealed "... II. Key Points: 1. Triage identifies who cannot wait to be seen and allows the ED to route patients as expeditiously as possible for definitive care to the appropriate emergency department area according to their priority. 2. Triage collaborates with the charge nurse regarding bed availability, ESI, and severity of patients in the waiting area. 3. Triage is to be considered a priority function. III. Purpose: To evaluate patients in the shortest possible period of time, to identify those illnesses or injuries requiring immediate emergency care. Accordingly, the triage system will address the necessary first aid for patients emergency care and will assist with patient/family understanding of the treatment environment. IV. Definitions: ESI: Emergency Severity Index: is a five-level emergency department (ED) triage algorithm that provides clinically relevant stratification of patients into five groups from 1 (most urgent) to 5 (least urgent) on the basis of acuity and resource needs (ESI, 2013). ... Level 2 - High risk situation, severe pain or distress ... VII. Intervention / Guideline: Guidelines: ... 5. An ESI of 4 or 5 can be accompanied by the ED intake personnel or volunteer or be called into the treatment area by the assigned nurse. All patient assigned an ESI of 2 will be accompanied by an appropriately trained staff member to a treatment area. When it becomes necessary for the triage staff member to accompany a patient to a treatment area, the responsibility for the patient should be assumed by the assigned nurse or charge nurse as soon as possible so that the triage staff member may return to the triage area ..."

Review of MR1 on October 29, 2021, at 10:30 a.m. revealed this patient presented to the facility's Emergency Department (ED) on October 26, 2021, at 1844, with the complaint of chest tightness beginning that day, radiating down both arms. The patient had a significant cardiac history of bypass surgery and placement of 14 stents. MR1 was transported from the ED waiting area to the triage area for an initial assessment, to determine the reason for the visit and an EKG. EMP2 and EMP4 determined MR1's Triage Acuity Level as a 2 (High risk) and returned MR1 to the ED waiting area.

Interview with EMP3 on October 29, 2021, at 10:45 a.m. confirmed MR1 presented to the facility's ED on October 26, 2021, at 1844, with the complaint of chest tightness beginning that day, radiating down both arms, and the patient had a significant cardiac history of bypass surgery and placement of 14 stents; MR1 was transported from the ED waiting area to the triage area for an initial assessment, to determine the reason for the visit and an EKG; and that EMP2 and EMP4 determined MR1's Triage Acuity Level as a 2 (High risk) and returned MR1 to the ED waiting area. EMP3 revealed EMP2 was an Agency Triage Registered Nurse and EMP4 was an Agency Charge Registered Nurse.

1. Review of MR1 on October 29, 2021, at 10:30 a.m. revealed no documentation this patient was taken directly to a treatment bed immediately on presentation to the greeter desk or following triage by a Registered Nurse (RN) for complaint of chest tightness.

Interview with EMP3, EMP5, EMP6 and EMP7 on October 29, 2021, at 10:45 a.m. confirmed MR1 contained no documentation this patient was taken directly to a treatment bed immediately on presentation to the greeter desk or following triage by an RN for complaint of chest tightness. EMP3 revealed the triage assessment was completed by a Registered Nurse (RN).

2. Review of MR1 on October 29, 2021, at 10:30 a.m. revealed no documentation this patient was placed on a cardiac monitor on presentation to the greeter desk or following triage by an RN for the complaint of chest tightness.

A request was made of EMP3, EMP5, EMP6 and EMP7 for cardiac rhythm strips for MR1 when this patient presented to the ED with the complaint of chest tightness with radiation down both arms. No cardiac rhythm strips were provided.

Interview with EMP3, EMP5, EMP6 and EMP7 on October 29, 2021, at 10:45 a.m. confirmed MR1 contained no documentation this patient was placed on a cardiac monitor on presentation to the greeter desk or following triage by an RN for complaint of chest tightness and the facility did not have cardiac rhythm strips for MR1. EMP3 confirmed cardiac rhythm strips would monitor and document changes in MR1's cardiac rhythm when having chest tightness.

3. Review of MR1 on October 29, 2021, at 10:30 a.m. revealed no documentation the facility inserted an Intravenous (IV) line following triage by an RN for complaint of chest tightness.

Interview with EMP3, EMP5, EMP6 and EMP7 on October 29, 2021, at 10:45 a.m. confirmed there was no documentation in MR1 indicating the facility inserted an IV line following triage by an RN for complaint of chest tightness. EMP3 confirmed the insertion of an IV line would be for an emergency should a patient need emergency medication.

4. Review of MR1 on October 29, 2021, at 10:30 a.m. revealed no documentation the facility administered oxygen therapy at 2 L (Liters) / m (minute) via nasal cannula following triage by an RN for complaint of chest tightness. There was no documentation in MR1 indicating the facility monitored MR1's oxygen saturation level and titrated this patient's oxygen level to ensure MR1's oxygen level did not go below 90 percent.

Interview with EMP3, EMP5, EMP6 and EMP7 on October 29, 2021, at 10:45 a.m. confirmed there was no documentation in MR1 indicating the facility administered oxygen therapy at 2 L/m via nasal cannula following triage by an RN for complaint of chest tightness or that the facility monitored MR1's oxygen saturation level and titrated this patient's oxygen level to ensure MR1's oxygen level did not go below 90 percent.
Review on October 29, 2021, at 11:15 a.m. of the facility's investigation of October 26, 2021, revealed MR1's family went to the ED triage desk and reported MR1 was beginning to have what was thought to be a seizure; EMP2 (Triage RN) assessed MR1 at 19:48 p.m. and determined this patient was in cardiac arrest, EMP2 called a Code and initiated CPR (Cardiopulmonary Resuscitation) in front of patients in the ED waiting area. Facility staff then transported MR1 from the ED waiting area to the Trauma Bay in the ED and placed this patient on a cardiac monitor. MR1 was ventricular tachycardia (a type of abnormal heart rhythm when the lower chamber of the heart beats too fast to pump well and the body does not receive enough oxygenated blood) and ventricular fibrillation (a severely abnormal heart rhythm or uncontrolled twitching or quivering of the heart muscle causing blood not to pump from the heart and that is life threatening and sudden cardiac death occurs).
Interview with EMP1, EMP6 and EMP7 on October 29, 2021, at 11:15 a.m. confirmed the facility's investigation of October 26, 2021, indicating MR1's family went to the ED triage desk and reported MR1 was beginning to have what was thought to be a seizure; EMP2 assessed MR1 at 19:48 p.m. and determined this patient was in cardiac arrest, EMP2 called a Code and initiated CPR in front of patients in the ED waiting area. EMP1, EMP6 and EMP7 confirmed facility staff then transported MR1 from the ED waiting area to the Trauma Bay in the ED and placed this patient on a cardiac monitor and that MR1 was ventricular tachycardia and ventricular fibrillation.

Interview with EMP3 on October 29, 2021, at 11:20 a.m. revealed the ED Trauma Bay was open and ready for patient use at the time of MR1's arrival to the ED and MR1 should have been taken to this room for cardiac monitoring, IV line insertion, administration of oxygen and treatment of chest tightness.

Review of MR1 on October 29, 2021, at 11:20 a.m. revealed MR1 was taken to the Cardiac Cath lab at 2105 where this patient expired.

Cross reference
482.13 (c)(2) Patient Rights: Care in Safe Setting
482.23 (a) Organization Of Nursing Services
482.23 (b) Staffing And Delivery Of Care
482.23 (b)(2) Licensure Of Nursing Staff
482.23 (b)(3) RN Supervision of Nursing Care
482.23 (b)5) Patient Care Assignments
482.23 (b)(6) Supervision Of Contract Staff