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Based on interviews, observations and document review, it was determined the facility's Quality Assurance and Performance Improvement Program failed to adequately address and correct known staffing and performance issues in the Emergency Department (ED). The noted staffing and performance issues continue to have an adverse effect on the quality of care provided to patients as evidenced by:

Review of ED staff 'worked schedules' evidenced that hospital staff failed to ensure sufficient nursing staff was available on all shifts, to ensure patient's needs were met. As a result, review of medical records showed that orders placed by providers were not followed, vital signs not monitored and/or assessed and/or documented and nursing assessments not completed.

During staff interviews and facility document review it was discovered that hospital staff failed to develop policy and or protocol defining the role of a Paramedic in the ED, resulting in non-nursing staff completing nursing assessments.

Review of personnel records and credentialing revealed that hospital staff failed to ensure ED staff providing patient care have received orientation, training, clinical skill evaluations and are acting within their role/job description as defined by hospital policy.

Based on information obtained during staff interviews, review of ED logs and observations of a high number of patients leaving this ED without being seen or before treatment, reinforced the problems with staffing and boarding of patients in the ED. The length of time the patients waited to be seen before leaving ED ranged from 20 to 640 minutes. The facility had no documented past or ongoing Quality monitoring activity for this area.

Please refer to A0283, A0392, A0398 and A1112 for further information supporting the finding of this Condition level deficiency.

Based on interview and document review, it was determined the facility's Quality Assurance and Performance Improvement Program failed to adequately address and correct known staffing and performance issues in the emergency department (ED).

The Findings Include:

See Tags A-0392, A-0398, and A-1112 for further details.

The surveyor noted a lack of documentation of nursing assessments and/or vital signs and NRP's (National Registered Paramedic) performing initial and ongoing assessments in the hospital's ED. The issues were discussed with SM #1 at the time of discovery during the record reviews for Patients #5, #12 and #13 on 7/27 and 7/28/22. SM #1 spoke to the problem of boarding patients in the ED while waiting for transfer and the unavailability of beds in receiving hospitals. SM #1 stated, they are contacting multiple hospitals without success and are being told by those hospitals the availability of beds is related to lack of staff at the receiving hospital to provide patient care. SM #1 stated, there are times when half of the ED's available beds (at this hospital) are being used by patients waiting for transfer or for admission to the hospital. (Per SM #7 Interim ED Director, at the present time, the hospital has capped the medical surgical beds at 14 due to lack of staffing for more beds, ICU beds had been capped at 6, also due to staffing issues.) SM #2 and SM #7 confirmed the boarding of patients in ED and the challenges in staffing (especially RN's) may have contributed to the failure to provide and document assessments and vitals per the ED protocol.

The hospital ED consists of 13 beds. SM #7 Interim ED Director (ED Director stepped down 4/22) was asked about staffing levels for the department. SM #7 responded they would like at least 3 nurses per shift and a tech/secretary and are working toward that goal. A provider is scheduled for each 12 hour shift and in addition an advanced practice provider (APP) is scheduled from 10 AM to 8 PM.

The following is a review of the staffing schedule for the days Patients #5, #12 and #13 were waiting for transfer. This does not include interns or staff in orientation. This does not include additional staff called in or pulled from other units and is only what was scheduled. Review of staffing schedule for ED found on 6/17/22: 3 RN's (registered nurse) and a tech/secretary for the 7 PM to 7 AM (night) shift. On 6/18/22: 7 AM-7 PM (day) 1 RN, 2 NRP's (nationally registered paramedic) and a tech/secretary. Night shift found 3 RN's and a tech/secretary. Staffing schedule for ED on 7/15/22: Day 1 RN, 1 NRP, and 1 LPN. Night 3 RNs. On 7/16/22: Day 1 RN, 2 NRP's and a tech/secretary. Night 3 RNs. On 7/17/22: Day 3 RNs and a tech/secretary. Night 3 RNs and a NRP. On 7/18/22: Day 1 RN, 1 NRP and a RN works 8 AM-3 PM Monday-Friday. Night 2 RNs, 1 NRP and a tech/secretary. On 7/19/22: Day 2 RN, 1 NRP, RN 8-3. Night 2 RNs and a tech/secretary. On 7/20/22: Day 1 RN, RN 8-3, and a tech/secretary. Night 1 RN, 1 NRP and a tech/secretary. On 7/21/22: Day 1 RN 8-3, 1 LPN, 1 NRP and a tech/secretary. Night 2 RNs, 1 NRP and a tech/secretary. On 7/22/22: Day 1 RN, 1 LPN and a tech/secretary. Night 2 RNs, 1 NRP and a tech/secretary.

The review revealed that staffing levels desired by SM #7 were not scheduled and although staff are being called in or pulled from other areas when available, this cannot be relied on. The surveyor was informed by SM #2, the hospital was not utilizing as many travel nurses since January. In February the Emergency Steering Committee meeting minutes documented an increase in patient volume in the ED with more positive Covid cases and a nursing turnover rate of 28.12 %.

Review of the ED log alerted the surveyor to the number of patients who are LWBS (leaving without being seen or before treatment). Review of 6/13/22 ED metrics found of 59 patients presenting to ED 39 % of patients LWBS (left without being seen). Length of wait time for those patients before leaving ranged from 20 to 640 minutes. The surveyor then reviewed the metrics and/or log for the days noted to have missing assessments for Patients #5, #12 and #13. Review for 6/17/22 of 58 patients presenting 17.2% LWBS. Review of 6/18/22 has 35 patients presenting to ED all are seen. 7/15/22 of 45 patients presenting 2 LWBS (4%). 7/16/22 of 49 patients 2 LWBS (4%). 7/17/22 of 39 patients 7 LWBS (17%). 7/18/22 of 50 patients presenting to ED 10 LWBS (20%). 7/19/22 of 47 patients 15 LWBS (32%). 7/20/22 of 44 patients 2 LWBS (4.5%). 7/21/22 of 49 patients 2 LWBS (4%).

Review of quality documents for Jan 2021-Dec 2021 found patients leaving without treatment was a known issue along with staff turnover, boarding of patients and limited transportation for transfers and discharged patients documented as an explanation. SM #2 reported a boarding policy was being developed and they were preparing an area where patients awaiting transfer may be placed but finding nurses to staff it may be a problem. The documents didn't contain an improvement plan for addressing staffing shortage/turnover, limited transportation and high number of patients leaving ED without treatment.

The surveyor reviewed the findings for a final time prior to exit on 7/29/22.

Based on interviews, observations and document review, it was determined the hospital failed to ensure sufficient qualified nursing staff in the Emergency Department (ED) was present to meet patients needs by following doctor's orders for monitoring, completing nursing assessments and delivering care in a timely manner.

Due to the lack of sufficient nursing staff available on all shifts, the facility staff failed to ensure acutely ill patient's needs were met while awaiting transfer to another hospital. As a result, orders placed by providers were not followed, vital signs not monitored and/or assessed and/or documented and nursing assessments completed by qualified staff for three (3) of four (4) ED patients in the sample were not completed.

Review of personnel records revealed that hospital staff failed to ensure Emergency Department (ED) staff providing patient care have recieved orientation, clinical skill evaluations and are acting within their role as defined by hospital policy.

Please refer to A0392 and A0398 for further information.

Based on interviews and document review, it was determined the hospital failed to provide nursing staff in the Emergency Department (ED) to ensure patient's needs were met for three (3) of four (4) ED patients in ED awaiting transfer to another hospital. (Patients #5, #12 and #13)

The findings include:

Patient #5: presented to the ED at 9:06 PM on 6/17/22 as a walk-in patient. The principal complaint was documented as "shortness of breath, adult". Patient #5 was called to triage at 11:09 PM. Triage documentation by Staff Member (SM) #3 included vital signs as follows "Temp 97.3 F, BP 148/71, Pulse 82, Resp 18, O2 Sat 98%. O2 Delivery 2L/m nasal cannula, Pain 0" and narrative noting "Pt's initial O2 87-88% RA placed pt on 2lpm via NC. Pt tolerated well. Pt does have +3 pitting BLE edema". Patient #5 was triaged as a level 3 and placed in room 03A.

A CT of the chest was ordered at 11:43 PM by SM #4, was completed at 1:36 AM on 6/18/22 with findings of a "large right lower lobe pulmonary mass which should be considered a malignant neoplasm until proven otherwise." The findings were communicated verbally to SM #4 at 3:28 AM. SM #4 documented at 4:15 AM on 6/18/22, the findings were discussed in detail with the patient who requested a transfer to (outside hospital).

Review of Patient #5's clinical record confirmed the unavailability of a bed until 6:30 PM on 6/18/22. Patient #5 was transferred at 4:36 AM on 6/19/22. Patient #5 was in ED awaiting transfer for more than 29 hours.

Review of the clinical record for Patient #5 failed to provide evidence of an initial nursing assessment after triage. Nursing assessment was documented on 6/18/22 at 8:32 PM and prior to transport on 6/19/22 at 4:36 AM by SM #5. There was no documentation of nursing assessments and/or nursing notes for a 20 hour period after Patient #5 was placed in a room. At 11:43 PM on 6/17/22, an order was placed for "continuous pulse ox, blood pressure monitor, cardiac monitor and vital signs every 15 min x 4, every 30 min x 4, then per order." SM #5 acknowledged the orders at 12:30 AM on 6/18/22. The vital signs were not obtained as ordered. Vital signs were documented at triage as noted with the next documented vital signs at 7 PM on 6/18/22, approximately 19 hours later. The clinical record contained no evidence Patient #5's cardiac status, blood pressure or oxygen levels were monitored during the aforementioned 19 hours.

Patient #12: presented to the ED on 7/15/22 at 10:34 AM via ambulance. The principal complaint was documented as bilateral diabetic leg wounds with weeping edema. Patient #12 was triaged at 11:17 AM by SM #12. Triage documentation by SM #3 included vital signs as follows, "Temp 98.3 F, BP 103/51, Pulse 68, Resp 18, O2 Sat 94%. Pain 0." Patient #12 was triaged as a level 2 and placed in room 08. Patient #12 was seen by SM #13 at 11:23 AM; a decision was made to transfer Patient #12 "for specialist wound care and further eval, care, tx of extensive gangrenous bilateral LE (lower extremities) wounds with cellulitis changes bilateral LE and groin" at 11:48 AM.

Review of Patient #12's clinical record confirmed the unavailability of a bed until 10:15 AM on 7/21/22. Patient #12 was transferred at 4:36 AM on 7/21/22. Patient #12 was in ED awaiting transfer for more than 5 days.

Review of the clinical record for Patient #12 found an initial nursing assessment completed at 5:55 PM by SM #12. The clinical record contained no evidence of a nursing assessment during the remainder of Patient #12's five (5) day stay. A transfer assessment was completed on 7/21/22 at 11:20 AM by SM #14 (a NRP (National Registered Paramedic employed by the hospital)). Vital signs were documented at triage as noted with the next documented blood pressure at 9:55 AM on 7/19/22, almost 4 days later. Vital signs documented next at 10:00 AM on 7/20/22 and prior to transfer on 7/21/22 at 10:23 AM. Pain levels were checked frequently during the stay.

Patient #13: presented to the ED at 5:28 PM on 7/16/22 via ambulance. The principal complaint was documented as "weakness, lethargy, hyperglycemia. Pt had a recent amputation of toes on his left foot, foot appears infected". Patient #13 was triaged at 5:42 PM by SM #15 (NRP). Triage documentation included vital signs as follows "Temp 99 F, BP 151/65, Pulse 106, Resp 18, O2 Sat 95%. Pain 0". Patient #13 was triaged as a level 2 and placed in room 10.

Patient #13 was seen by SM #16 at 8:28 PM on 7/16/22. The decision was made to transfer the patient for treatment of diabetic foot infection and vascular and/or general surgery for possible amputation. At 9:44 PM, patient was accepted for transfer to (hospital) but no bed available possibly until 7/18/22.

Review of Patient #13's clinical record confirmed the unavailability of a bed until Patient #13 was transferred at 12:45 PM on 7/21/22. Patient #13 was in ED awaiting transfer for more than 4 days.

Review of the clinical record for Patient #13 failed to provide evidence of an initial nursing assessment after triage. Assessment was documented on 7/16/22 at 5:28 PM by SM #15 (NRP), assessment on 7/17/22 at 6:48 AM by SM #5 and prior to transport on 7/21/22 at 12:45 PM by SM #15. There was no documentation of nursing assessments for more than 4 days between 7/17/22 and 7/21/22. Two Rounding/Safety/Hygiene assessments were documented on 7/19/22 and one on 7/20/22. Vital signs were documented at triage as noted with the next documented vital signs are at 7:24 PM on 7/19/22, (approx 3 days later) during a hypotensive episode with blood pressure of 80/62, pulse 103, respiratory 20 and O2 sats 97% on 4 lpm nasal cannula. Vital signs were documented prior to transfer at 12:40 PM on 7/21/22. It was noted Patient #13's heart rate and oxygen level were documented every 15 minutes from 6:45 PM on 7/20/22 to 5:30 AM on 7/21/22.

The issue with nursing assessments for patients who are being housed in the ED waiting for transfer to outside hospitals was discussed with SM #1. SM #1 spoke to the problem of boarding patients in the ED while waiting for transfer and the unavailability of beds in receiving hospitals. SM #1 stated they are contacting multiple hospitals without success and are being told by those hospitals the availability of beds is related to lack of staffing at the receiving hospital. SM #1 explained there are times when half of the ED's available beds are being used by patients waiting for transfer or for admission to the hospital. (Per SM #7 Interim ED Director, at the present time the hospital has capped the medical surgical beds at 14 due to lack of staffing for more beds, ICU beds had been capped at 6 also due to staffing issues.) SM #2 and SM #7 confirmed the boarding of patients in ED and the challenges in staffing (especially RN's) may have contributed to the failure to provide and document assessments and vitals per the ED protocol.

The hospital ED consists of 13 beds. SM #7 Interim ED Director (ED Director stepped down 4/22) was asked about staffing levels for the department. SM #7 responded they would like at least 3 nurses per shift and a tech/secretary and are working toward that goal. A provider is scheduled for each 12 hour shift and an advanced practice provider (APP) is scheduled from 10 AM to 8 PM.

The following is a review of the staffing schedule for the days Patients #5, #12 and #13 were waiting for transfer. This does not include interns or staff in orientation. This does not include additional staff called in or pulled from other units and is only what is scheduled. Review of staffing schedule for ED found on 6/17/22: 3 RN's (registered nurse) and a tech/secretary for the 7 PM to 7 AM (night) shift. On 6/18/22: 7 AM-7 PM (day) 1 RN, 2 NRP's (nationally registered paramedic) and a tech/secretary. Night shift found 3 RN's and a tech/secretary. Staffing schedule for ED on 7/15/22: Day 1 RN, 1 NRP, and 1 LPN. Night 3 RNs. On 7/16/22: Day 1 RN, 2 NRP's and a tech/secretary. Night 3 RNs. On 7/17/22: Day 3 RNs and a tech/secretary. Night 3 RNs and a NRP. On 7/18/22: Day 1 RN, 1 NRP and a RN works 8 AM-3 PM Monday-Friday. Night 2 RNs, 1 NRP and a tech/secretary. On 7/19/22: Day 2 RN, 1 NRP, RN 8-3. Night 2 RNs and a tech/secretary. On 7/20/22: Day 1 RN, RN 8-3, and a tech/secretary. Night 1 RN, 1 NRP and a tech/secretary. On 7/21/22: Day 1 RN 8-3, 1 LPN, 1 NRP and a tech/secretary. Night 2 RNs, 1 NRP and a tech/secretary. On 7/22/22: Day 1 RN, 1 LPN and a tech/secretary. Night 2 RNs, 1 NRP and a tech/secretary.

The review revealed that staffing levels desired by SM #7 were not scheduled and although staff were being called in or pulled from other areas when available, this cannot be relied on. The surveyor was informed by SM #2, the hospital was not utilizing as many travel nurses since January. In February the Emergency Steering Committee meeting minutes documented an increase in patient volume in the ED with more positive Covid cases and a nursing turnover rate of 28.12 %.

The failure to complete nursing assessments and vital sign checks for acutely ill patients for extended periods of time was discussed with SM #1, SM #2 and SM #7 several times during the survey and opportunity was given for the presentation of additional documentation and/or explanation. SM #1 stated to the surveyor that if the assessments and/or vital signs were not in the information provided to the surveyor, they just "weren't there".

In addition review of the ED log revealed a consistently high number of patients who are LWBS (leaving without being seen or before treatment). Review of 6/13/22 ED metrics found 59 patients presenting to ED that day and 39 % of patients LWBS (left without being seen). The surveyor reviewed also metrics and/or log for the days when assessments for Patients #5, #12 and #13 were missing, and found a high numbers of patients left the ED without being seen due to extended wait times (more than 5 hours) caused by staff and beds shortage.

A review of hospital policy "NUR-ED 141 Guidelines for Triage, Vital Signs and Assessments (Adult/Pediatric), 93054. Review of the policy found the following in part: "Patients presenting for emergency medical treatment shall be screened for level of acuity by an emergency trained registered nurse..." "C. Emergency department patient vital signs will be taken according to triage priority as follows: 1. All level 1 & 2 patients who are no longer unstable are reassessed, to include vital signs at least hourly. Temperatures will be done if condition warrants. If unstable, the vitals will be based on condition or md orders. 2. ESI level 3: every 2 hours or based on condition." "Initial Assessment to include ABCDs is also required each time the patient care is turned over to a new nurse. E. The RN will utilize assessment techniques and criteria that are pertinent to the patient's age specific physical, developmental, cognitive, and psychosocial needs." "The nurse will carry out all documented orders/interventions that the medical provider has ordered for the patient in the Emergency Department Setting."

Review of hospital policy "ADM 103 EMTALA - Medical Screening and Treatment of Emergency Medical Conditions" effective 08/2021 read in part as follows: "e. A Medical Screening Examination is not an isolated event. The record must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred."

The surveyor reviewed the findings with the management team for a final time prior to exit on 7/29/22.

Based on interview and document review, it was determined hospital staff failed to ensure Emergency Department (ED) staff providing patient care have received orientation, clinical skill evaluations and are acting within their role as defined by hospital policy.

The findings include:

Patient #12 presented to the ED on 7/15/22 at 10:34 AM via ambulance. The principal complaint was documented as bilateral diabetic leg wounds with weeping edema. Patient #12 was triaged at 11:17 AM by SM #12. Triage documentation by SM #3 includes vital signs as follows "Temp 98.3 F, BP 103/51, Pulse 68, Resp 18, O2 Sat 94%. Pain 0." Patient #12 was triaged as a level 2 and placed in room 08. Patient #12 was seen by SM #13 at 11:23 AM; a decision was made to transfer Patient #12 for specialist wound care and further eval, care, tx of extensive gangrenous bilateral LE wounds with cellulitis changes bilateral LE and groin" at 11:48 AM.

Review of Patient #12's clinical record confirmed the unavailability of a bed until 10:15 AM on 7/21/22. Patient #12 was transferred at 4:36 AM on 7/21/22. Patient #12 was in ED awaiting transfer for more than 5 days.

Review of the clinical record for Patient #12 found an initial nursing assessment completed at 5:55 PM by SM #12. The clinical record contained no evidence of a nursing assessment during the remainder of Patient #12's five (5) day stay. A transfer assessment was completed on 7/21/22 at 11:20 AM by SM #14 (a NRP (National Registered Paramedic employed by the hospital)). The assessment included an assessment of skin/wounds. Vital signs were documented at triage as noted with the next documented blood pressure at 9:55 AM on 7/19/22, almost 4 days later. Vital signs documented next at 10:00 AM on 7/20/22 and prior to transfer on 7/21/22 at 10:23 AM. Pain levels were checked frequently during the stay.

Two Paramedics are utilized in the ED. Review of training records for 2 of 2 Paramedics found computer based learning to be up to date but found no orientation to ED or skill evaluations. As the transfer assessment was completed by a NRP, the surveyor requested a hospital policy defining the tasks a NRP is allowed to perform in the hospital/ED. Hospital policy "Nur-ED 132, Pre-Hospital Care Providers" effective 12/2015 was provided. Surveyor review found the policy addressed educational and clinical opportunities for area EMS and ambulance services. The policy is specific to clinical time for non-hospital staff and does not speak to what tasks a NRP can or cannot perform when employed by the hospital and providing patient care in the hospital settings. Review of the job description for "ED Med Tech - Paramedic 11.16.2020" found in part under "Essential Functions": "provides direct patient care as directed by RN, prepares patient for exams, specimen collection, maintain a neat, well-stocked work environment, keep charge nurse informed of daily activities and developments, work with computer software, maintain confidentiality,...". The job description did not address what nursing tasks can be delegated to a paramedic and how paramedic's skills would be evaluated before they are permitted to be perform the nursing tasks.

The absence of a hospital policy defining the role of a NRP in the ED, (including if a NRP was allowed to complete nursing assessments) was discussed with Staff #1 and Staff #2. Staff #1 stated they had searched for definitive guidelines for the actions of a NRP in the hospital setting but had not been able to find anything.

Surveyor review of the "Guidance Document Scope of Practice Procedures and Formulary" https://www.vdh.virginia.gov/content/uploads/sites/23/2022/03/Scope-of-Practice-Formulary.pdf (retrieved 12/06/22) found guidance for out of hospital practice only.

Review of "12VAC5-31-1050. Scope of practice.
EMS personnel shall only perform those procedures, skills, or techniques for which he is currently licensed or certified, provided that he is acting in accordance with local medical treatment protocols and medical direction provided by the OMD of the licensed EMS agency with which he is affiliated and within the scope of the EMS agency licenses as authorized in the Emergency Medical Services Procedures and Medications Schedule as approved by the board."

A review of hospital policy "NUR-ED 141 Guidelines for Triage, Vital Signs and Assessments (Adult/Pediatric), 93054." effective 3/2022. Review of the policy found the following in part: "Patients presenting for emergency medical treatment shall be screened for level of acuity by an emergency trained registered nurse..." "Initial Assessment to include ABCDs is also required each time the patient care is turned over to a new nurse. E. The RN will utilize assessment techniques and criteria that are pertinent to the patient's age specific physical, developmental, cognitive, and psychosocial needs." "The nurse will carry out all documented orders/interventions that the medical provider has ordered for the patient in the Emergency Department Setting." The policy does not address assessments being completed by staff other than nurses.

The above findings were reviewed with the management team prior to exit.

Based on interviews and document review, it was determined the hospital failed to provide adequate nursing staff in the Emergency Department (ED) to ensure patients' needs are met for two (2) of four (4) ED patients (Patients #12 and #13), failed to ensure ED staff were adequately trained and failed to develop policy and or protocol defining the role of a Paramedic in the ED.

The findings include:

Patient #12 presented to the ED on 7/15/22 at 10:34 AM via ambulance. The principal complaint was documented as bilateral diabetic leg wounds with weeping edema. Patient #12 was triaged at 11:17 AM by SM #12. Patient #12 was triaged as a level 2 and placed in room 08. Patient #12 was seen by SM #13 at 11:23 AM; a decision was made to transfer Patient #12 for specialist wound care and further eval, care, tx of extensive gangrenous bilateral LE wounds with cellulitis changes bilateral LE and groin" at 11:48 AM.

Review of Patient #12's clinical record confirmed the unavailability of a bed until 10:15 AM on 7/21/22. Patient #12 was transferred at 4:36 AM on 7/21/22. Patient #12 was in ED awaiting transfer for more than 5 days. Review of the clinical record for Patient #12 found an initial nursing assessment completed at 5:55 PM by SM #12. The clinical record contained no evidence of a nursing assessment during the remainder of Patient #12's five (5) day stay. A transfer assessment was completed on 7/21/22 at 11:20 AM by SM #14 (a NRP (National Registered Paramedic employed by the hospital)). Vital signs were documented at triage as noted with the next documented blood pressure at 9:55 AM on 7/19/22, almost 4 days later. Vital signs documented next at 10:00 AM on 7/20/22 and prior to transfer on 7/21/22 at 10:23 AM. Pain levels were checked frequently during the stay.

Patient #13 presented to the ED at 5:28 PM on 7/16/22 via ambulance. The principal complaint was documented as "weakness, lethargy, hyperglycemia. Pt had a recent amputation of toes on his left foot, foot appears infected". Patient #13 was triaged at 5:42 PM by SM #15 (NRP). Patient #13 was triaged as a level 2 and placed in room 10.

Patient #13 was seen by SM #16 at 8:28 PM on 7/16/22. The decision was made to transfer the patient for treatment of diabetic foot infection and vascular and/or general surgery for possible amputation. At 9:44 PM, patient was accepted for transfer to (hospital) but no bed available possibly until 7/18/22. Review of Patient #13's clinical record confirmed the unavailability of a bed until Patient #13 was transferred at 12:45 PM on 7/21/22. Patient #13 was in ED awaiting transfer for more than 4 days.

Review of the clinical record for Patient #13 failed to provide evidence of an initial nursing assessment after triage. Assessment was documented on 7/16/22 at 5:28 PM by SM #15 (NRP), assessment on 7/17/22 at 6:48 AM by SM #5 and prior to transport on 7/21/22 at 12:45 PM by SM #15. There was no documentation of nursing assessments for more than 4 days between 7/17/22 and 7/21/22. Two Rounding/Safety/Hygiene assessments were documented on 7/19/22 and one on 7/20/22. Vital signs were documented at triage as noted with the next documented vital signs are at 7:24 PM on 7/19/22, (approx 3 days later) during a hypotensive episode with blood pressure of 80/62, pulse 103, respiratory 20 and O2 sats 97% on 4 lpm nasal cannula. Vital signs were documented prior to transfer at 12:40 PM on 7/21/22. It was noted Patient #13's heart rate and oxygen level were documented every 15 minutes from 6:45 PM on 7/20/22 to 5:30 AM on 7/21/22.

The following is a review of the staffing schedule for the days Patients #12 and #13 were waiting for transfer. This does not include interns or staff in orientation. This does not include additional staff called in or pulled from other units and is only what is scheduled. Review of staffing schedule for ED found on 7/15/22: Day 1 RN, 1 NRP, and 1 LPN. Night 3 RNs. On 7/16/22: Day 1 RN, 2 NRP's and a tech/secretary. Night 3 RNs. On 7/17/22: Day 3 RNs and a tech/secretary. Night 3 RNs and a NRP. On 7/18/22: Day 1 RN, 1 NRP and a RN works 8 AM-3 PM Monday-Friday. Night 2 RNs, 1 NRP and a tech/secretary. On 7/19/22: Day 2 RN, 1 NRP, RN 8-3. Night 2 RNs and a tech/secretary. On 7/20/22: Day 1 RN, RN 8-3, and a tech/secretary. Night 1 RN, 1 NRP and a tech/secretary. On 7/21/22: Day 1 RN 8-3, 1 LPN, 1 NRP and a tech/secretary. Night 2 RNs, 1 NRP and a tech/secretary. On 7/22/22: Day 1 RN, 1 LPN and a tech/secretary. Night 2 RNs, 1 NRP and a tech/secretary.

The lack of documented nursing assessments and vital signs for acutely ill patients for extended periods of time was discussed with SM #1, SM #2 and SM #7 multiple times during the survey and opportunity was given for the presentation of additional documentation and/or explanation. SM #1 stated to the surveyor that if the assessments and/or vital signs were not in the information provided to the surveyor, they just "weren't there".

As noted above, Patient #12 and Patient #13 have assessments completed by a NRP. The surveyor requested a hospital policy defining the tasks a NRP is allowed to perform in the hospital/ED. Hospital policy "Nur-ED 132, Pre-Hospital Care Providers" effective 12/2015 was provided. Surveyor review found the policy addressed educational and clinical opportunities for area EMS and ambulance services. The policy is specific to clinical time for non-hospital staff and does not speak to what tasks a NRP can or cannot perform when employed by the hospital. Review of the job description for "ED Med Tech - Paramedic 11.16.2020" found in part under "Essential Functions": provides direct patient care as directed by RN, prepares patient for exams, specimen collection, maintain a neat, well-stocked work environment, keep charge nurse informed of daily activities and developments, work with computer software, maintain confidentiality, etc. The job description did not address what nursing tasks are permitted to be performed.

The absence of a hospital policy defining the role of a NRP in the ED, (including if a NRP was allowed to complete nursing assessments) was discussed with Staff #1 and Staff #2. Staff #1 stated they had searched for definitive guidelines for the actions of a NRP in the hospital setting but had not been able to find anything.

Surveyor review of the "Guidance Document Scope of Practice Procedures and Formulary" https://www.vdh.virginia.gov/content/uploads/sites/23/2022/03/Scope-of-Practice-Formulary.pdf (retrieved 12/06/22) found guidance for out of hospital practice only.

Review of "12VAC5-31-1050. Scope of practice. EMS personnel shall only perform those procedures, skills, or techniques for which he is currently licensed or certified, provided that he is acting in accordance with local medical treatment protocols and medical direction provided by the OMD of the licensed EMS agency with which he is affiliated and within the scope of the EMS agency licenses as authorized in the Emergency Medical Services Procedures and Medications Schedule as approved by the board."

The surveyor was informed unit manager(s) are responsible for developing the orientation to their units and the documentation of such. Unit managers are also responsible for ensuring staff have completed HealthStream learning/training. Unit managers and the employees who have not completed assigned training will receive email notification.

Surveyor review of training and orientation records for Staff assigned to the ED found 8 of 8 RN Staff to have general orientation to the hospital but no orientation to the ED documented (new staff were excluded from count). Four of eight RN Staff have past due HealthStream learning including but not limited to courses in Sedation Compliance, Violent Restraints, Suicide Risk Assessment, Drug Diversion, ESI Triage Annual Training, Pain Management, EMTALA and Rapid Response. The review did not include Staff who are not dedicated ED staff.
Two Paramedics were utilized in the ED. Review of training records for 2 of 2 Paramedics found computer based learning to be up to date but found no unit orientation or skill evaluations.

Concerns related to training and staffing were discussed with Staff #1 and Staff #2 multiple times during the course of the survey. Staff #1 and Staff #2 stated the lack of documented orientation and the failure to ensure education is completed by ED staff may be a attributed to the absence of a ED director for at least the last 6 months. An interim Director was appointed but was overseeing the ICU as well. Healthcare Compliance Committee (HCC) Meeting Minutes for the past year were reviewed.

Review of "Emergency Steering Committee" minutes for 7/18/22 reads in part "Nurse staffing still a challenge HR is having sevral (sic) recruiting events to help improve staffing."The hospital is utilizing Paramedics and LPNs (Licensed Practical Nurse) in the ED and currently has two RN Interns working part-time. A Director for the ED has been hired and is in orientation. A 2 day nursing "Boot Camp" is held monthly for new hires (if any).

The failure to provide adequate nursing staff to provide for patient care needs, ensure staff received adequate orientation and training and to define the role of the NRP in the ED was reviewed with the management team prior to exit.