HospitalInspections.org

Based on observation, interview and record review the facility failed to:


A. ensure patients presenting to the Emergency Department with chest pain and elevated blood sugar received consistent assessments, timely implementation of facility protocols and monitoring by qualified nurses. This deficient practice was found in 2 of 2 patients (Patient #3 and 10).

This deficient practice had the likelihood to cause harm in all patients.

Findings include:
Review of an "Emergency Record" revealed Patient #3 was a 57 year old female, who presented on 10/12/2014 at 1:15 p.m. Review of a triage assessment timed 2:41 p.m., revealed Patient #3's chief complaint was chest pain. Patient #3 complained of having intermittent episodes of chest pain that radiated to her left shoulder and arm with headache and nausea/vomiting times one week. Patient #3 had a pain level of 8 out of 10 (1 being the lowest pain and 10 being the highest pain). There was no documentation of nursing interventions that were implemented to address the chest pain.

Review of an "Emergency Physician Record" revealed that Physician #5 performed his assessment at 3:10 p.m. ( 1 hour and 55 minutes) after Patient #3 presented to the Emergency Department.

Review of the Emergency Department order sheet revealed no listed orders from the physician. The only lab on the chart was a complete blood count and the time collected was at 3:18 p.m. (over 2 hours after presenting to the Emergency Department). An EKG was performed on Patient #3, but the time ran on the strip was incorrect. The calibration was off on the equipment.

Review of a nursing assessment timed 3:37 p.m. revealed that Patient #3 left Against Medical Advice, stating she was going to another hospital.

During an interview on 10/13/2014 after 3:30 p.m., Staff #2 confirmed they were having problems with nursing putting in there assessments timely. Staff #2 reported the initial nursing assessment was actually performed at 1:30 p.m. Staff #2 confirmed the physician screening was performed late, time on the EKG strip was incorrect, and nursing staff failed to implement their chest pain protocol.

Review of an undated policy named "Emergency Department Nurse Protocols" revealed the following regarding chest pain:

Notify Physician arrival
Call for EKG and show physician within 5 minutes
O2 @ 2L/min per nasal cannula
Give Nitroglycerin/ASA as ordered (must question patient/EMT if it has/has not been given
Cardiac, BP and Pulse OX monitors
Saline Lock (Consider Twin Lumen catheter)
Lab:CBC, BMP, CK, CK-MB, Troponin, PT/PTT, Digoxin if indicated, extra tubes. May order Cardiac Triage Panel.
Portable chest x-ray
Old chart if indicated.

Review of an "Emergency Record" revealed Patient #10 was a 17 year old female, who presented on 10/06/2014 at 4:25 p.m.

Review of the "Emergency Physician Record" (physician screening) revealed that he failed to document the time he saw Patient #10.

Review of a nursing triage report revealed Patient #10 presented with hyperglycemia (elevated blood sugar) and had an elevated pain level of 10 out of 10. The assessment was completed by Staff #2 at 4:42 p.m..

Review of the personnel file on Staff #2 revealed she had a job description for an Emergency Department team leader/RN. One of the responsibilities listed was for the staff member to assume responsibility for their own personal continuing education and developmental needs, attend safety in-service, infection control, CPR certification in-services, ACLS in-service, and bi-yearly TB testing. Staff #2's last ACLS certification expired on 09/2014.

Review of the emergency department order sheet revealed the physician failed to time the orders. There was an order for an insulin drip, Normal saline bolus, Regular insulin per sliding scale (16 units IVP intravenous push), fasting blood sugars and sodium bicarbonate 2 ampules IVP. There was also a protocol for sliding scale insulin which was not complete with how often to perform accuchecks. The protocol called for a medium dose regimen which staff could use during Patient #10's stay.

The following was documented regarding Patient #10's blood sugar:
4:25 p.m. Regular insulin 16 units IVP administered
5:02 p.m. the blood sugar was elevated at 891 (reference ranges being 75-110)
7:10 p.m. Regular insulin 7 units her hour IVP

Review of documentation dated 7:40 p.m. revealed that Patient #10 was transferred to another hospital.

There was no other documentation on the chart of nursing monitoring the patient's blood sugar. There was no documentation of what the blood sugar was prior to discharge.

During an interview on 10/13/2014 after 3:30 p.m., Staff #2 confirmed not being able to find additional blood sugar monitoring.


B. ensure there was sufficient numbers of nursing staff and failed to ensure supervision was provided on 2 of 2 units (Emergency department and Medical surgical unit).

During an interview on 10/13/2014 at 11:40 a.m., Staff #2 reported that they had a current in-patient census of 4. There were currently 2 Registered nurses (RN), 1 Licensed vocational nurse (LVN) and Patient care technician (PCT) on duty. This was what they normally scheduled on every shift. The staff on the Medical surgical unit floated to the Emergency Department (ED) when needed.

During an observation on 10/13/2014 after 12:11 p.m., both RN's (Staff #s' 8 and 9) were working in the ED. They were in and out of patients rooms on the ED unit. The LVN and PCT were still on the Medical-Surgical unit without RN supervision. The two units were separated by doors and an enclosed nursing station.

During an interview on 10/13/2014 at 12:29 p.m., Staff #2 reported that Staff #9 (designated ED RN) was the house supervisor also. The charge nurses had to work as House Supervisor in addition to their other duties.

During an interview on 10/13/2014 at 12:46 p.m., Staff #8 reported she works both sides (ED and MS unit). Staff #8 confirmed the LVN and PCT are left on the unit alone while she works the ED. Staff #8 reported it gets scary.

During an interview on 10/13/2014 at 12:50 p.m., Staff #7(LVN) reported her and the PCT are left alone on the Medical-Surgical unit.

During an interview on 10/13/2014 at 1:00 p.m., Staff #9 reported the PCT and LVN are left alone when both (RNs) are triaging patients. Staff #9 reported "it gets hairy sometimes."

Review of the Census reports from 09/30 -10/12/2014 revealed there were patients on the medical surgical unit every day during this timeframe. The average daily census in the ED during this timeframe was from 15-26 patients.

Review of the "Nurse Staffing Board " timesheets from 9/28-10/12/2014 revealed the following staffing for the ED and Medical Surgical unit:

*6:00 a.m.-6:00 p.m. shift
2 RNs, 1 LVN and 1 PCT, 8 out of 14 days;

*6:00 p.m.-6:00 a.m.
2 RNs, 1 LVN and 1 PCT, 10 out of 14 days;
On 10/05/2014 there was 1 RN, 2 LVNs and 1 PCT scheduled.

During an interview on 10/13/2014 at 1:45 p.m., Staff #2 confirmed the staffing numbers. Staff #2 also confirmed they had no staffing patterns/grid/matrix to follow for the minimum amount of staff needed.
Review of a facility policy named "Staffing" dated 07/2002 revealed the following:
There must be a registered nurse available to the unit at all times ....
I.A. A professional registered nurse must complete/do the assignment of nursing care on each nursing unit or in each nursing department. The assignment must be based on the following:
3. Approved staffing patterns and /or patient classifications data regarding acuity, census, and staffing policies.
Review of a facility policy named "Nurse Staffing Plan" dated 06/2004 revealed the following:
C. At a minimum, the staffing levels are based on the following factors:
1. Patient characteristics and number of patients for whom care is being provided, including:
a. Number of admissions
b. Number of transfers
c. Number of discharges
2. Intensity of care provided as well as the variability of care on the nursing unit.
3. Scope of services provided.
4. Consideration of:
a. Architecture and geography of the unit
b. Availability of technology
c. Availability of supplies and equipment
d. Availability of support personnel
e. Other appropriate factors that affect patient care
5. Staff characteristics including:
a. Tenure
b. Preparation and experience
c. Number and competencies of clinical and non clinical support staff the nurse must collaborate with or supervise.


C. ensure nursing staff used proper infection control techniques during the cleaning process after patients were discharged from the rooms on 2 of 2 units (Emergency department and Medical-Surgical).
During an observation on 10/13/2014, after 12:45 p.m., Staff #9 (ED RN) was cleaning a room in the ED after discharging a patient. Staff #9 brought unbagged soiled linen that was removed from the cot in the room and discarded it in an area across the hallway. Staff #9 was also observed cleaning the mattress on the bed and she did not have on anything to protect her uniform. Afterwards Staff #9 was observed to assist with care on another patient.
During an observation on 10/13/2014, after 1:15 p.m., Staff #7 (MS LVN) was cleaning a room on the Medical surgical unit after a patient was discharged. Staff #7 was observed stripping linen from the bed and cleansing the mattress on the bed. Staff #7 had no protective gear over her uniform. During an interview Staff #7 reported that after she gets through housekeeping comes and do their part.
Review of a facility policy named "Cleaning for Rooms Vacated by Discharged Patients" dated 03/01/2011 revealed:
1. Prior to housekeeping coming in to clean the room all linens, IV pumps, and any other equipment is removed by nursing staff.
There was nothing in the policy about nursing wearing protective gear over their uniforms during this cleaning process.

Based on interview and record review the facility failed to ensure medical records were accurate and complete in 7 of 7 patients (Patient #s' 1, 3, 5, 6, 7, 9 and 10).

This deficient practice had the likelihood to cause harm in all patients.

Findings include:

Review of an "Emergency Record" revealed Patient #3 was a 57 year old female, who presented on 10/12/2014 at 1:15 p.m.
Review of a triage assessment timed 2:41 p.m., revealed Patient #3 chief complaint was chest pain. Patient #3 complained of having intermittent episodes of chest pain that radiated to her left shoulder and arm with headache and nausea/vomiting times one week. Patient #3 had a pain level of 8 out of 10 (1 being the lowest pain and 10 being the highest pain). There was no documentation of nursing interventions that were implemented to address the chest pain.
Review of an "Emergency Physician Record" revealed Physician #5 performed his assessment at 3:10 p.m. ( 1 hour and 55 minutes) after Patient #3 presented to the Emergency Department.

Review of the Emergency Department order sheet revealed no listed orders from the physician. The only lab on the chart was a complete blood count and the time collected was at 3:18 p.m. (over 2 hours after presenting to the Emergency Department). An EKG was performed on Patient #3, but the time ran on the strip was incorrect. The calibration was off on the equipment.

Review of a nursing assessment timed 3:37 p.m. revealed Patient #3 left Against Medical Advice, stating she was going to another hospital.

During an interview on 10/13/2014 after 3:30 p.m., Staff #2 confirmed they were having problems with nursing putting in there assessments timely. Staff #2 reported the initial nursing assessment was actually performed at 1:30 p.m. Staff #2 confirmed the physician screening was performed late, time on the EKG strip was incorrect and nursing staff failed to implement their chest pain protocol.
Review of an undated policy named "Emergency Department Nurse Protocols" revealed the following regarding chest pain:

Notify Physician arrival
Call for EKG and show physician within 5 minutes
O2 @ 2L/min per nasal cannula
Give Nitroglycerin/ASA as ordered (must question patient/EMT if it has/has not been given
Cardiac, BP and Pulse OX monitors
Saline Lock (Consider Twin Lumen catheter)
Lab:CBC, BMP, CK, CK-MB, Troponin, PT/PTT, Digoxin if indicated, extra tubes. May order Cardiac Triage Panel.
Portable chest x-ray
Old chart if indicated.

Review of an "Emergency Record" revealed Patient #10 was a 17 year old female, who presented on 10/06/2014 at 4:25 p.m.
Review of the "Emergency Physician Record" (physician screening) revealed he failed to document the time he saw Patient #10.
Review of a nursing triage report revealed Patient #10 presented with hyperglycemia (elevated blood sugar) and had an elevated pain level of 10 out of 10. The assessment was completed by Staff #2 at 4:42 p.m..
Review of the personnel file on Staff #2 revealed she had a job description for an Emergency Department team leader/RN. One of the responsibilities listed was for the staff member to assume responsibility for their own personal continuing education and developmental needs, attend safety in-service, infection control, CPR certification in-services, ACLS in-service, and bi-yearly TB testing. Staff #2's last ACLS certification expired on 09/2014.
Review of the emergency department order sheet revealed the physician failed to time the orders. There was an order for an insulin drip, Normal saline bolus, Regular insulin per sliding scale (16 units IVP intravenous push), fasting blood sugars and sodium bicarbonate 2 ampules IVP. There was also a protocol for sliding scale insulin which was not complete with how often to perform accuchecks. The protocol called for a medium dose regimen which staff could use during Patient #10's stay.
The following was documented regarding Patient #10's blood sugar:
4:25 p.m. Regular insulin 16 units IVP administered
5:02 p.m. the blood sugar was elevated at 891 (reference ranges being 75-110)
7:10 p.m. Regular insulin 7 units her hour IVP
Review of documentation dated 7:40 p.m. revealed Patient #10 was transferred to another hospital.
There was no other documentation on the chart of nursing monitoring the patient's blood sugar. There was no documentation of what the blood sugar was prior to discharge.
During an interview on 10/13/2014 after 3:30 p.m., Staff #2 confirmed not being able to find additional blood sugar monitoring.

Review of an "Emergency Record' revealed Patient #1 was an 83 year old female, who presented on 10/13/2014 at 0026 a..m. Review of an "Emergency Physician Record" at 0030 a.m. revealed Patient #1 had a low blood sugar of 37.
Review of the Emergency Room order sheets revealed the medication orders were written underneath wrong section on the form. They were written underneath the x-ray section instead of the section designated for medications.

Review of an "Emergency Record" revealed Patient #7 was a 54 year old male, who presented on 10/10/2014 at 12:25 p.m.
Review of a nursing triage report revealed Patient #7 presented at 12:57 p.m. and was triaged at 1:00 p.m. Patient #7 presented with complaints of shortness of breath and fatigue.
Review of an emergency physician orders on Patient #7 revealed they were not timed by the physician or nursing.

Review of a nursing triage report on Patient #5 revealed he was an 84 year old male who presented at 1:25 p.m. with a chief complaint of chest pain.
Review of the emergency physician record revealed the physician failed to document the time he saw the patient.
Review of the physician order revealed they were not timed as to when they were written.

Review of a nursing triage report on Patient #6 revealed she was a 28 year old female, who presented on 10/10/2014 at 1:10 p.m. for abdominal pain. The triage report was documented as being performed at 2:38 p.m. Another nursing assessment was timed for 1:30 p.m. was found on the chart. There was a discrepancy in the time the patient was initially assessed.


Review of an "Emergency Record" revealed Patient #9 was a 93 year old male, who presented at 5:08 p.m. on 10/09/2014.
Review of the emergency physician record revealed the physician failed to document the time he performed the assessment.
Review of physician orders revealed the patient was in for chest pain and that the orders were signed off by nursing and the physician at 8:30 p.m. (over 3 hours later).

Review of the undated Medical Staff Rules and Regulations revealed the following:
"A physician member of the Medical Staff shall be responsible for the medical care and treatment of each patient in the Hospital, and for accurately and promptly completing the medical record.
Pertinent progress notes shall be recorded at the time of observation, sufficient to permit continuity of care and transferability.
All clinical entries in the patient's medical record shall be accurately dated and authenticated by written signature or identifiable initials of the responsible practitioner."