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Based on a review of clinical records, facility documentation, staff interviews, and Emergency Department's policies and procedures, it was determined that the hospital failed to meet the Condition of Participation for Emergency Services as evidenced by:

a. The failure to accurately triage three of ten sampled Emergency Department (ED) patients' (Patient #1, #8 and #10), who presented with abdominal pain and additional signs of severe pain including but not limited to hypertension, tachycardia, diaphoresis, agitation and pupil dilation in accordance with the hospital policy.

b. The failure to ensure a timely evaluation by a Licensed Independent Practitioner (LIP) for four of ten sampled ED patients' (Patient #3, #5, #6 and #7), who were triaged as a level two (2) with additional signs of severe pain including but not limited to hypertension, tachycardia, diaphoresis, agitation and pupil dilation in accordance with the hospital policy.

c. The failure to obtain physician's order for one sampled ED patient (Patient #1), for the administrations of medications.

d. The failure to reassess vital signs for five of ten ED patients' (Patient #1, #4, #6, #7, and #10) in accordance with the triage policy.

e. The failure to identify that Emergency Department patients' (triaged as a level two) were evaluated within five (5) minutes by a LIP when a pain alert was initiated in accordance with the hospital guideline entitled, Emergency Department Pain Alert. Please refer to A-1104.

The findings include the following:

1. Based on a review of clinical records, staff interviews, hospital documentation, and Emergency Department's policies and procedures, the hospital failed to accurately triage three of ten patients' (Patient #1, #8 and #10), in the Emergency Department in accordance with the hospital's policies and procedures. The findings included:

a. Review of the clinical record identified Patient #1 was admitted to the Emergency Department (ED) via ambulance on 8/26/16 at 7:15 PM with complaints of sudden onset epigastric pain radiating to his/her neck described as "pressure". Patient #1 complained of severe pain identified as a level ten (on a scale of 0-10 with 10 being the worst possible pain) and a blood pressure of 173/74 mm Hg (Normal is less than 120/80 mm Hg). Patient #1 was triaged as a level three high that indicated his/her condition could progress to a serious problem that required emergency intervention according to the Triage policy. Patient #1 was placed on a stretcher in the hallway of the triage area. An electrocardiogram (EKG) was ordered via protocol by RN #1 and completed at 7:21 PM to rule out an acute cardiac event. The EKG was reviewed by MD #3. An abdominal protocol was initiated by RN #3 at 8:49 PM that included the insertion of a peripheral line, a complete blood cell count with differential, a comprehensive metabolic profile, an amylase and lipase level and a urinalysis. Maalox 30 milliliters (ml) orally (po) and Lidocaine Viscous 10 ml po were administered by RN #3 at 8:59 PM absent a physician's order. Repeat vital signs were taken at 9:24 PM and were documented as 149/60 mm Hg. At 10:01 PM the patient stood up and fell to the floor in full cardiac arrest. Cardiopulmonary resuscitation was initiated and continued unsuccessfully. Patient #1 was pronounced deceased at 10:21 PM. On 9/19/16 the Office of the Chief Medical Examiner indicated the cause of death was an aortic dissection due to hypertensive cardiovascular disease. Interview with MD #3 on 9/13/16 at 10:05 AM stated she reviewed the EKG and did not identify ST elevation on the tracing (non-ST Elevation Myocardial Infarction (NSTEMI). Interview with MD #2 on 9/9/16 at 10:38 AM indicated he was unaware of Patient #1's status or that laboratory testing was obtained. MD #2 stated if he was made aware of the patient's severe pain with associated hypertension he would have seen the patient regardless of his/her location and/or triage level. Interview with RN #1 on 9/9/16 at 1:15 PM who was the triage nurse, identified although Patient #1 was hypertensive she assigned a triage level "three high" as the patient was not in severe distress. RN #1 further identified that the patient was maintained at the triage area as no beds were available. Interview and review of the triage assessment with the Director of the ED on 9/9/16 at 2:00 PM indicated RN #1 failed to accurately complete the "vital sign alert" portion of the triage as RN #1 documented the vital sign alert as "no". The Director further stated that if the vital sign alert was identified by the triage nurse as "yes" the patient's triage level would have been a "two" and ultimately led to a timely evaluation by a LIP. Patient #1 failed to be seen by a LIP until 10:01 PM when cardiopulmonary arrest was identified (2 hours and 46 minutes after arrival).

b. Review of the clinical record identified Patient #8 was admitted to the ED on 9/1/16 at 11:24 AM with complaints of abdominal pain after a recent cholecystectomy four days prior. Patient #8 was placed in a room and triaged simultaneously at 11:36 AM with an assigned triage level of "three high". The patient indicated his/her pain level was a ten (10) with an admitting blood pressure of 183/82 mm Hg. Patient #8 was evaluated by a LIP at 12:36 PM. Diagnostic testing, analgesics and antiemetic's were ordered. Patient #8 was admitted to an inpatient unit. Interview and review of the clinical record with the Director of the ED on 9/9/16 at 2:15 PM identified the vital sign alert was not initiated by the triage nurse therefore the triage remained a level three high when it should have been a level two secondary to severe pain with accompanying hypertension.

c. Review of the clinical record identified Patient #10 was admitted to the ED on 9/3/16 at 8:46 AM with complaints of abdominal pain. Patient #10 was placed in a room at 9:02 AM with a triage level of three. The patient indicated his/her pain was a nine out of ten with an admitting blood pressure of 172/79 mm Hg. The patient was evaluated by a LIP at 9:20 AM and found to have asthma symptoms. Patient #10 was treated with bronchodilators and steroids and was discharged to home at 4:45 PM. Interview and review of the clinical record with the Director of the ED on 9/9/16 at 2:25 PM identified the vital sign alert was not initiated by the triage nurse therefore the triage level remained a three when it should have been a level two due to severe pain with associated hypertension.

The hospital policy entitled, "Emergency Severity Index Triage, General Guidelines", directed in part that triage would involve a rapid, directed patient assessment by a Registered Nurse which provided an assignment of an acuity level for each patient arriving in the ED. A Triage ESI level two (2) was defined as a patient who presented with a condition posing a potential threat to life and required rapid medical intervention. The nurse would assess the patient and identify the appropriate level of care by completing the rapid triage assessment and full triage assessment. A Triage ESI three (3) High was defined as a patient with a condition that could progress to a serious problem requiring emergency intervention. The vital signs of the patient may or may not be outside normal limits and the presenting condition was anticipated to require the utilization of two or more resources. A full triage assessment would be completed at times of high volume and acuity when a bed is not readily available.

The hospital guideline entitled, "Emergency Department Pain Alert", directed in part to identify and rapidly treat a patient who presented with severe pain. If the patient's pain rating was identified as 7-10/10 and additional signs of severe pain were present including but not limited to diaphoresis, tachycardia, hypertension, agitation, and pupil dilation the registered nurse would activate a pain alert. The guideline further directed if the patient was in the triage area, they will be brought back to a room immediately. If the patient was in a room, the primary nurse would notify the LIP or the charge nurse. The LIP would assess the patient within five minutes of arrival to a room. If the LIP was not present within five minutes, the charge nurse would request a specific physician assessment. If a physician could not make themselves available, the charge nurse would notify the ED Medical Director immediately.

2. Based on a review of clinical records, staff interviews. and Emergency Department's policies and procedures, for four of ten patient's who were triaged as a level two with a vital sign alert (Patient #3, #5, #6, and #7), the facility failed to ensure a timely evaluation by a Licensed Independent Practitioner (LIP) in accordance with the facilities policies and procedures. The findings included:

a. Review of the clinical record identified Patient #3 was admitted to the Emergency Department (ED) on 9/1/16 at 4:24 PM with complaints of abdominal pain. Patient #3 was triaged at 4:35 PM with an assigned ESI level of two. The patient indicated his/her pain level was a ten, with associated diaphoresis. Patient #3 was placed into a room at 4:55 PM and evaluated by LIP at 5:34 PM, thirty-nine minutes after the patient was assigned to a room. The hospital failed to ensure the patient was evaluated within five minutes of arriving to a room in accordance with facility policy.

b. Review of the clinical record identified Patient #5 was admitted to the ED on 9/11/16 at 12:04 AM with complaints of abdominal pain. Patient #5 was triaged at 12:07 AM with an assigned ESI level of two. The patient indicated his/her pain level was a nine out of ten with associated hypertension (blood pressure 155/104 mm Hg). Patient #5 was placed into a room at 12:17 AM and evaluated by a LIP at 12:36 AM, nineteen minutes after the patient was assigned to a room. The hospital failed to ensure the patient was evaluated within five minutes of arriving to a room in accordance with facility policy.

c. Review of the clinical record identified Patient #6 was admitted to the ED on 9/11/16 at 12:22 PM with complaints of abdominal pain. Patient #6 was triaged at 12:29 PM with an assigned ESI level of two. The patient indicated his/her pain level was a seven out of ten with associated hypertension (blood pressure 176/104 mm Hg). Patient #6 was placed into a room at 2:03 PM and evaluated by a LIP at 2:52 PM, forty-nine minutes after the patient was assigned to a room. The hospital failed to ensure the patient was evaluated within five minutes of arriving to a room in accordance with facility policy.

d. Review of the clinical record identified Patient #7 was admitted to the ED on 9/1/16 at 1:58 AM with complaints of abdominal pain. Patient #7 was triaged at 2:01 AM with an assigned ESI level of two. The patient indicated his/her pain level was a ten with associated hypertension (blood pressure 206/116 mm Hg), and presence of vasoconstriction. Patient #7 was placed into a room at 2:13 PM and evaluated by a LIP at 2:45 PM, thirty-two minutes after the patient was assigned to a room. The hospital failed to ensure the patient was evaluated within five minutes of arriving to a room in accordance with facility policy.

Interview with the Director of the Emergency Room on 9/12/16 at 2:00 PM identified Patient #3, #5, #6 and #7 were all triaged as an ESI level two with additional signs of severe pain which activated a pain alert. The Director of the ED indicated that although all these patients were assigned to a room, the patients were not evaluated by a LIP within five minutes in accordance with hospital policy. The Director identfied that the primary nurse is responsible to notify the charge nurse and/or LIP that the patient needs to be evaluated. Interview with MD #2 on 9/9/16 at 10:40 AM identified that even if a patient was not assigned to room in the emergency area he would come and assess any patient in any location at the request of a registered nurse.

The hospital guideline entitled, "Emergency Department Pain Alert", directed in part to identify and rapidly treat a patient who presented with severe pain. If the patient's pain rating was identified as 7-10/10 and additional signs of severe pain were present including but not limited to diaphoresis, tachycardia, hypertension, agitation, and pupil dilation the registered nurse would activate a pain alert. The guideline further directed if the patient was in the triage area, they will be brought back to a room immediately. If the patient was in a room, the primary nurse would notify the LIP or the charge nurse. The LIP would assess the patient within five minutes of arrival to a room. If the LIP was not present within five minutes, the charge nurse would request a specific physician assessment. If a physician could not make themselves available, the charge nurse would notify the ED Medical Director immediately.

3. Based on a clinical record review, staff interviews and a review of the Emergency Department's protocols for one of ten patients' (Patient #1), the facility failed to obtain a physician's order for the administration of medications. The finding included:

a. Review of Patient #1's clinical record identified on 8/26/16 at 8:59 PM, Maalox 30 milliliters (ml) orally (po) and Lidocaine viscous 10 ml po was ordered by RN #3 and administered at 8:59 PM. Review of the clinical record and ED protocol with RN #3 on 9/12/16 at 10:55 AM identified she ordered Maalox and Lidocaine Viscous absent a physician's order and/or protocol and should not have.

4. Based on a clinical record review, staff interviews and a review of the Emergency Department's policies and procedures for five of ten patients reviewed for nursing assessments in the emergency department (Patient #1, #4, #6, #7, and #10), the facility failed to conduct vital sign reassessments in accordance with the hospital policy. The findings included:

a. Review of the clinical record identified Patient #1 was admitted to the Emergency Department (ED) via ambulance on 8/26/16 at 7:15 PM with complaints of sudden onset epigastric pain radiating to his/her neck described as "pressure". Patient #1 complained of severe pain identified as a level ten (on a scale of 0-10 with 10 being the worst possible pain) and a blood pressure of 173/74 mm Hg (Normal is less than 120/80 mm Hg). Patient #1 was triaged as a level three high that indicated his/her condition could progress to a serious problem that required emergency intervention according to the Triage policy. Vital signs were re-taken at 9:24 PM. Interview and review of the triage assessment with the Director of the ED on 9/9/16 at 2:00 PM indicated RN #1 failed to accurately complete the "vital sign alert" portion of the triage as RN #1 documented the vital sign alert as "no". The Director further stated that if the vital sign alert was identified by the triage nurse as "yes" the patient's triage level would have been a "two" and vital signs reassessments would have been conducted hourly. Further interview with the Director of the ED identified the triage nurse was responsible for Patient #1 and failed to complete hourly vital sign reassessments in accordance with the hospital policy.

b. Review of the clinical record identified Patient #4 was admitted to the ED on 9/1/16 at 12:43 AM with complaints of epigastric pain. Patient #4 was triaged at 12:44 AM as a level two with an admitting blood pressure of 210/120 mm Hg. Patient #4 was admitted to an inpatient unit on 9/1/16 at 7:58 AM for the treatment of hypertension. Vital signs were conducted at 2:49 AM, 3:49 AM, and 4:49 AM. Interview with the Director of the ED on 9/14/16 indicated vital signs failed to be conducted hourly in the ED until admission to the inpatient unit in accordance with the hospital policy.

c. Review of the clinical record identified Patient #6 was admitted to the ED on 9/11/16 at 12:22 PM with complaints of abdominal pain. Patient #6 was triaged at 12:29 PM as a level two with an admitting blood pressure of 176/104 mm Hg. The patient was admitted to an inpatient unit at 7:23 PM for hypertension and an positive troponin level. Review of the clinical record identified vital signs were taken at 2:30 PM, 3:12 PM, 3:56 PM, 4:30 PM and 4:56 PM. Interview with the Director of the ED on 9/14/16 indicated vital signs failed to be conducted hourly in the ED until admission to the inpatient unit in accordance with the hospital policy.

d. Review of the clinical record identified Patient #7 was admitted to the ED on 9/1/16 at 1:58 AM with complaints of abdominal pain. Patient #7 was triaged at 2:01 AM as a level two with an admitting blood pressure of 206/110 mm Hg. The patient was discharged from the ED on 9/1/16 at 1:21 PM. Vital signs were conducted on 9/1/16 at 2:28 AM, 3:30 AM, 4:25 AM, 5:25 AM, 7:02 AM, and at 9:02 AM. Interview with the Director of the ED on 9/14/16 indicated vital signs failed to be conducted hourly throughout the patients admission in the ED in accordance with the hospital policy.

e. Review of the clinical record identified Patient #10 was admitted to the ED on 9/3/16 at 8:46 AM with complaints of abdominal pain. Patient #10 was triaged at 9:02 AM as a level three with an admitting blood pressure of 172/79 mm Hg. The patient was evaluated by a LIP at 9:20 AM and found to have asthma symptoms. Vital signs were conducted at 9:45 AM, 12:11 PM and 4:29 PM. Patient #10 was treated with bronchodilators/steroids and was discharged to home at 4:45 PM. Interview and review of the clinical record with the Director of the ED on 9/9/16 at 2:25 PM identified that level three patient's require vital sign monitoring every two (2) hours in accordance with policy and that was not done.

The hospital policy entitled, "Emergency Department Nursing Documentation Guidelines", directed in part that clinical/narrative documentation for level two and three acuity levels would be conducted every two hours unless otherwise indicated by clinical status. The policy further directed that vital signs would be taken every hour for level two acuity and every two hours for level three acuity.

Based on a review of clinical records, a review of the Quality Assurance and Performance Improvement meeting minutes, hospital documentation, interviews, and policies, for four of ten sampled Emergency Department patients' (Patient #3, #5, #6 and #7), the facility failed to identify that triage level two patients were evaluated by a Licensed Independent Practitioner (LIP) within five minutes when a pain alert was activated in accordance with the hospital guideline entitled Emergency Department Pain Alert. The findings included:

a. Review of the clinical record identified Patient #3 was admitted to the Emergency Department (ED) on 9/1/16 at 4:24 PM with complaints of abdominal pain. Patient #3 was triaged at 4:35 PM with an assigned ESI level of two. The patient indicated his/her pain level was a ten, with associated diaphoresis. Patient #3 was placed into a room at 4:55 PM and evaluated by LIP at 5:34 PM, thirty-nine minutes after the patient was assigned to a room. The hospital failed to ensure the patient was evaluated within five minutes of arriving to a room in accordance with facility policy.

b. Review of the clinical record identified Patient #5 was admitted to the ED on 9/11/16 at 12:04 AM with complaints of abdominal pain. Patient #5 was triaged at 12:07 AM 2 with an assigned ESI level of two. The patient indicated his/her pain level was a nine out of ten with associated hypertension (blood pressure 155/104 mm Hg). Patient #5 was placed into a room at 12:17 AM and evaluated by a LIP at 12:36 AM, nineteen minutes after the patient was assigned to a room. The hospital failed to ensure the patient was evaluated within five minutes of arriving to a room in accordance with facility policy.

c. Review of the clinical record identified Patient #6 was admitted to the ED on 9/11/16 at 12:22 PM with complaints of abdominal pain. Patient #6 was triaged at 12:29 PM with an assigned ESI level of two. The patient indicated his/her pain level was a seven out of ten with associated hypertension (blood pressure 176/104 mm Hg). Patient #6 was placed into a room at 2:03 PM and evaluated by a LIP at 2:52 PM, forty-nine minutes after the patient was assigned to a room. The hospital failed to ensure the patient was evaluated within five minutes of arriving to a room in accordance with facility policy.

d. Review of the clinical record identified Patient #7 was admitted to the ED on 9/1/16 at 1:58 AM with complaints of abdominal pain. Patient #7 was triaged at 2:01 AM with an assigned ESI level of two. The patient indicated his/her pain level was a ten with associated hypertension (blood pressure 206/116 mm Hg), and presence of vasoconstriction. Patient #7 was placed into a room at 2:13 PM and evaluated by a LIP at 2:45 PM, thirty-two minutes after the patient was assigned to a room. The hospital failed to ensure the patient was evaluated within five minutes of arriving to a room in accordance with facility policy.

Review of the QAPI minutes during the period of 10/13/15 through 8/9/16 failed to reflect documentation that identified the facility was tracking compliance with the hospital guideline entitled, "Emergency Department Pain Alert".

Interview with the Director of the Emergency Room on 9/12/16 at 2:00 PM identified Patient #3, #5, #6 and #7 were all triaged as a level two with additional signs of severe pain which activated a pain alert and should have been evaluated by a LIP within five minutes of arrival to a room in the ED.

Interview with the Director of the Emergency Department (ED) and MD #1 (Medical Director of the ED) on 9/14/16 at 11:00 AM confirmed that the hospital was not tracking/monitoring level two patients who were identified as "a vital sign alert" from the time of triage to the time of an evaluation by a LIP and should have. Subsequent to the surveyors inquiry the ED Director immediately initiated random audits to ensure compliance with the Pain Alert Guideline.

The hospital guideline entitled, "Emergency Department Pain Alert", directed in part to identify and rapidly treat a patient who presented with severe pain. If the patient's pain rating was identified as 7-10/10 and additional signs of severe pain were present including but not limited to diaphoresis, tachycardia, hypertension, agitation, and pupil dilation the registered nurse would activate a pain alert. The guideline further directed if the patient was in the triage area, they will be brought back to a room immediately. If the patient was in a room, the primary nurse would notify the LIP or the charge nurse. The LIP would assess the patient within five minutes of arrival to a room. If the LIP was not present within five minutes, the charge nurse would request a specific physician assessment. If a physician could not make themselves available, the charge nurse would notify the ED Medical Director immediately.

The Hospital Performance Improvement Plan directed in part to establish an infrastructure and processes needed to assess, analyze, design and improve systems and processes that impact patients, employees and medical staff. Clinical areas would utilize unit-specific indicators to assess the quality of care and high risk clinical presentations.