HospitalInspections.org

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


A. provide evidence the Quality Assurance Program was monitoring for infections.


Refer to tag C0278 for additional information.



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B. ensure sufficient number of Registered nurses to provide supervision and provide patient care on 2 of 2 units (Emergency Department and Medical Surgical).

Refer to tag C0296 for additional information.


C. ensure ensure 5 of 5 patients received accurate assessments, continual monitoring and timely interventions in the Emergency Department (Patient's # 1, 3, 7, 11, and 14.)
Refer to tag C0298 for additional information.


D. ensure 5 of 5 patients records were complete and accurate in the Emergency Department (Patient's # 1, 3, 7, 11, and 14.)


Refer to tag C0302 for additional information.

Based on document review and interview the facility failed to provide evidence the Quality Assurance Program was monitoring for infections.
A review of the document titled Performance Improvement Plan, Department: Infection Control revealed Key department processes require routine monitoring in order to ensure effective and safe care to those served. Infection control issues will be reviewed monthly and summarized and reported quarterly to the Infection Control Committee. Significant findings and trends will be monitored:
Healthcare associated infections (HAIs)
Device-related infections
Antibiotics-resistant organisms
HAI TB
Other communicable diseases
Employee health trends
An interview with staff #2 revealed Infection Control was not monitoring antibiotic-resistant organisms, healthcare associated infections (HAIs), or employee health trends. Staff #2 revealed Influenza and pneumococcal vaccines were not offered for elderly patients.




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During an observation on 12/08/2014 after 1:15 p.m. the following was found in the ED:
*The outside of the lab cart had a buildup of dust and inside of the drawers were soiled with particles. The base at the back of the cart was covered with spider webs.
* In the trauma room was a suction set up stored on top of a crash cart. Both the setup and cart were covered with a layer of dust and the base of the cart was covered with spider webs.
Inside a supply cabinet was 2 mini bore extension sets which expired November 2014 and a glass evacuated container which expired October 2014.
*During an observation of the physical therapy room on 12/08/2014 after 3:50 p.m., a hydrocoillator was found. The inside walls of the equipment had a buildup of brown substance and was rusted. The wire racks holding the heating packs inside the equipment had a build-up of brown substance.

Based on observation, interview, and record review the facility failed to ensure a sufficient number of Registered Nurses (RN) to provide supervision and patient care on 2 of 2 units the Emergency Department (ED) and Medical Surgical(MS).
This deficient practice had the likelihood to cause harm to all patients.
Findings include:
During an interview on 12/08/2014 after 2:15 p.m. Staff #3 reported they try to have 3 RN's in the facility, but that does not always happen. When they do not have 3 RN's they get an extra Licensed Vocational Nurse (LVN) to help out. Staff #3 reported she got to work today at 5:45 a.m. and was the only staff working the ED. Staff #3 reported having approximately 11 patients come through the ED so far today. After 1:00 p.m. an LVN came in to help her today.
During an interview on 12/08/2014 at 3:10 p.m., Staff #5 reported since the last time the staffing is somewhat better. She reported they have one RN in the ED. There was one RN, one LVN, and one tech on the medical/surgical unit. They were planning to have RN positions to cover 11:00 a.m.-11:00 p.m. and 12:00 p.m.-12 midnight. Someday's they have someone come in during that timeframe, but it is sporadic. There was two LVN's there today, but one was an orientee who just started. Staff #5 reported this morning she went over to help Staff #13 in the ED to start an IV, but that was the only time today. She had to leave the LVN's and tech on the Medical -Surgical unit alone. There was no way she could go back and help the ED nurse because she had 4 admits on the medical-surgical unit and was up to 7 patients now.
During an observation on 12/09/2014 at 11:30 a.m., Staff #5 left the nurses station on the Medical -Surgical side. She reported she had to go and help in the ED to triage two patients. Staff #21 (LVN) was left on the Medical-Surgical unit without RN supervision.
During an interview on 12/10/2014 at 9:15 a.m., Staff #8 (Staffing coordinator) reported she was working as much as she could to cover the openings (in the schedule). They were having a hard time getting nurses to fill the positions (11:00 a.m.-11:00 p.m.) The new hires they do have were not ready for the ED because they were not ACLS certified. There was only one time where there was one RN for the entire facility, but it was only for 2 hours.
Review of the Census reports for December 2014 revealed there were patients on the medical surgical unit every day during from 12/01-08/2014. The patient census ranged from 4-10. The average daily census in the ED during this timeframe was from 11-27 patients.
Review of December 2014 timesheets for the Emergency Department and Medical Surgical unit revealed the following:
*6:00 a.m.-6:00 p.m. shift
2 RN's and 1 LVN, 4 out of 8 days
1 RN and 1 LVN, 1 out of 8 days
*6:00 p.m.-6:00 a.m.
2 RN's and 1 LVN 6 out of 8 days;
1 RN and 1 LVN 1 out of 8 days;
And 1 RN, 1 out of 8 days.
During an interview on 12/10/2014 after 10:45 a.m., Staff #1 confirmed the staffing numbers. Staff #1 provided a written statement dated 12/10/2014 of steps she had taken to improve the staffing numbers. On 11/28/2014 she met with the system CNO (chief nursing officer) to try for staff assistance and again on 12/09/2014 and no one was available.
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 the staffing grid for the Medical unit dated November 2014 revealed the following:
A census of 1-10 called for 2 nurses (RN/LVN) for both day and night shift.

Based on interview and record review the facility failed to ensure 5 of 5 patients received accurate assessments, continual monitoring, and timely interventions in the Emergency Department (Patient's # 1, 3, 7, 11, and 14.)
This deficient practice had the likelihood to cause harm in all patients:
Findings include:
Review of Emergency Department (ED) Triage report revealed Patient #1 was a 32 year old male who presented on 12/08/2014 at 2:29 p.m. and was triaged at 2:30 p.m. by nursing. There was documentation he presented with complaints of swelling down his throat and into his ear. Patient #1 had a blood pressure of 140/90 and a pain level of 8 out of 10 (0 indicating no pain and 10 being severe pain).
Review of the Physician Record revealed his assessment was at 2:20 p.m. (before presentation). Review of the Physician Record revealed Patient #1 had acute pain in maxilla/mandible-due to dental caries, abscess, and gingivitis. Documentation revealed the pain was resolved after septocaine (meaning septocaine/articaine is an anesthetic agent). Review of physician orders which were not timed by the physician or nursing revealed no orders for an anesthetic agent. There was no documentation of the neither time nor amount of anesthetic agent administered.
There was no documentation of continued pain assessment, monitoring after an anesthetic agent, nor any other vital signs prior to discharge by nursing.
Review of a discharge summary on Patient #1 revealed they were timed for 2:44 p.m. and signed off by nursing at 3:14 p.m. There was no documented time of when the patient signed the form.
Review of an ED Triage Report dated 12/08/2014 revealed Patient #11 was a 4 year old female who presented at 12:33 p.m. because of being sent home from school with an elevated temperature of 102. Nursing documented the following vital signs: 99.5 degrees Fahrenheit temperature, 128 beat per minute pulse, and respirations of 14. There was no documentation of a blood pressure.
Review of the Emergency Physician Record dated 12/08/2014 revealed no documentation of the time the patient was screened by the physician.
Review of the record revealed Patient #11 was discharged at 2:08 p.m.
The initial set of vital signs was the only documented vital signs on the patient. There was no blood pressure documented on the record at all.
Review of an ED Triage report revealed Patient #7 was a 36 year old male who presented on 12/05/2014 at 5:03 p.m. with chest pain. Review of the triage assessment revealed no documented assessment of the pain level on presentation to the ED. The pain portion of the assessment was left blank. Patient #7 had a blood pressure of 147/97 on presentation.
Review of the ED Physician record dated 12/05/2014 revealed no documented time of when the physician performed his medical screening. According to the Physician record revealed Patient #7 had chest pain and it was at a level of 6.
Review of the physician orders revealed no date or time they were written. There was an order for Aspirin and Nitroglycerin written on the form. There was documentation after the Aspirin order of the time 7:42 p.m. (over 2 hours after presentation) indicating administration time. Behind the Nitroglycerin order revealed documentation of no chest pain, but there was no time documented.
Review of the daily focus assessment report dated 12/05/2014 revealed Patient #7 was discharged at 10:30 p.m. There was no documentation of a continued assessment of vital signs on the patient.
Review of an ED Triage report revealed Patient #3 was a 46 year old female who presented 11/16/2014 with coughing after receiving a flu shot. Review of the ED record revealed no time documented of when the patient received a medical screening.
Review of physician orders revealed they were not dated or timed. There were orders for respiratory treatments, antibiotic, and steroid medications on the sheet which did not include the frequency or route to administer.
Review of an ED Triage report dated 09/05/2014 revealed Patient #14 was a 54 year old female who presented on 09/05/2014 at 9:40 a.m. with chest pain. Patient #14 had an elevated blood pressure of 161/105 and a pain level of 10 out of 10 (1 lowest range of pain and 10 being the highest amount of pain). An Aspirin was administered at 9:58a.m. Nitroglycerin was administered at 9:58 a.m. and at 10:00 a.m. without any documentation of vital signs being recorded. The next documented blood pressure was at 1:56 p.m. and it was still 161/105.
The first documentation of an intravenous site being started was at 2:12 p.m.
During an interview on 12/10/2014 after 10:00 a.m., Staff #2 confirmed the problems with assessment in the emergency room charts.
Review of Nursing Policy and Procedures dated 09/2014 revealed the following:

Title:" Pain Assessment and Management"
A. Pain control is a patient's right. The patient experiencing pain will be appropriately assessed and interventions will be made within 30 minutes to provide pain relief.
C. The physicians will prescribe all medications and other pain management interventions and oversee the pain control/management of their patients.
E. Each patient will be initially assessed on admission, and thereafter as necessary, by nursing service staff for pain location, duration, onset, intensity, character, and any existing method used for pain control, the frequency of use of pain control and its effectiveness. Licensed nursing staff will, in addition to assessments, administer and initially evaluate the success of pain control/management measures. Once initiated, each patient should be reassessed after each medication dose and as needed concerning pain control/management. The physicians should be notified if pain control measures are ineffective. This will be documented in the patient's medical record.

Title: "Medications Administration in Emergency Room"
I. A. Medication may be given to a patient only upon the order of an individual with clinical privileges or of an authorized member of staff.
II. A. The ER (emergency room) sheet shall be maintained to reflect date, time, medication, dosage, frequency and route of administration as ordered by the physician as well as the initials and signature of that person administering medication.

Title: "ED Record Charting"
Purpose: To provide documentation of the Emergency Department patient from arrival to disposition.
1. Upon Patient's arrival to ED document the following:
D. Pain Level
E. Vital Signs

Based on interview and record review the facility failed to ensure 5 of 5 patients records were complete and accurate in the Emergency Department (Patient's # 1, 3, 7, 11, and 14.)
This deficient practice had the likelihood to cause harm in all patients:
Findings include:
Review of Emergency Department (ED) Triage report revealed patient #1 was a 32 year old male who presented on 12/08/2014 at 2:29 p.m. and was triaged at 2:30 p.m. by nursing. There was documentation he presented with complaints of swelling down his throat and into his ear. Patient #1 had a blood pressure of 140/90 and a pain level of 8 out of 10 (0 indicating no pain and 10 being severe pain).
Review of the Physician Record revealed his assessment was at 2:20 p.m. (before presentation). Review of the Physician Record revealed Patient #1 had acute pain in maxilla/mandible-due to dental caries, abscess, and gingivitis. Documentation revealed the pain was resolved after septocaine (meaning septocaine/articaine is an anesthetic agent). Review of physician orders which were not timed by the physician or nursing revealed no orders for an anesthetic agent. There was no documentation of the neither time or amount of anesthetic agent administered.
There was no documentation of continued pain assessment, monitoring after an anesthetic agent nor any other vital signs prior to discharge by nursing.
Review of a discharge summary on patient #1 revealed they were timed for 2:44 p.m. and signed off by nursing at 3:14 p.m. There was no documented time of when the patient signed the form.
Review of an ED Triage Report dated 12/08/2014 revealed patient #11 was a 4 year old female who presented at 12:33 p.m. because of being sent home from school with an elevated temperature of 102. Nursing documented the following vital signs: 99.5 degrees Fahrenheit temperature, 128 beat per minute pulse, and respirations of 14. There was no documentation of a blood pressure.
Review of the Emergency Physician Record dated 12/08/2014 revealed no documentation of the time the patient was screened by the physician.
Review of the record revealed Patient #11 was discharged at 2:08 p.m.
The initial set of vital signs was the only documented vital signs on the patient. There was no blood pressure documented on the record at all.
Review of an ED Triage report revealed patient #7 was a 36 year old male who presented on 12/05/2014 at 5:03 p.m. with chest pain. Review of the triage assessment revealed no documentation of an assessment of the pain level on presentation to the ED. The pain portion of the assessment was left blank. Patient #7 had a blood pressure of 147/97 on presentation.
Review of the ED Physician record dated 12/05/2014 revealed no documented time of when the physician performed his medical screening. According to the Physician record revealed Patient #7 had chest pain and it was at a level of 6.
Review of the physician orders revealed no date or time they were written. There was an order for Aspirin and Nitroglycerin written on the form. There was documentation after the Aspirin order of the time 7:42 p.m. (over 2 hours after presentation) indicating administration time. Behind the Nitroglycerin order revealed documentation of no chest pain, but there was no time documented.
Review of the daily focus assessment report dated 12/05/2014 revealed Patient #7 was discharged at 10:30 p.m. There was no documentation of a continued assessment of vital signs on the patient.
Review of an ED Triage report revealed Patient #3 was a 46 year old female who presented 11/16/2014 with coughing after receiving a flu shot. Review of the ED record revealed no time documented of when the patient received a medical screening.
Review of physician orders revealed they were not dated or timed. There were orders for respiratory treatments, antibiotic, and steroid medications on the sheet which did not include the frequency or route to administer.
Review of an ED Triage report dated 09/05/2014 revealed Patient #14 was a 54 year old female who presented on 09/05/2014 at 9:40 a.m. with chest pain. Patient #14 had an elevated blood pressure of 161/105 and a pain level of 10 out of 10 (1 lowest range of pain and 10 being the highest amount of pain). An Aspirin was administered at 9:58 a.m. Nitroglycerin was administered at 9:58 a.m. and at 10:00 a.m. without any documentation of vital signs being recorded. The next documented blood pressure was at 1:56 p.m. and it was still 161/105.
The first documentation of an intravenous site being started was at 2:12 p.m.
During an interview on 12/10/2014 after 10:00 a.m., Staff #2 confirmed the problems with assessment in the emergency room charts.
Review of Nursing Policy and Procedures dated 09/2014 revealed the following:
Title:" Pain Assessment and Management"
A. Pain control is a patient's right. The patient experiencing pain will be appropriately assessed and interventions will be made within 30 minutes to provide pain relief.
C. The physicians will prescribe all medications and other pain management interventions and oversee the pain control/management of their patients.
E. Each patient will be initially assessed on admission, and thereafter as necessary, by nursing service staff for pain location, duration, onset, intensity, character, and any existing method used for pain control, the frequency of use of pain control and its effectiveness. Licensed nursing staff will, in addition to assessments, administer and initially evaluate the success of pain control/management measures. Once initiated, each patient should be reassessed after each medication dose and as needed concerning pain control/management. The physicians should be notified if pain control measures are ineffective. This will be documented in the patient's medical record.

Title: "Medications Administration in Emergency Room"
I. A. Medication may be given to a patient only upon the order of an individual with clinical privileges or of an authorized member of staff.
II. A. The ER (emergency room) sheet shall be maintained to reflect date, time, medication, dosage, frequency and route of administration as ordered by the physician as well as the initials and signature of that person administering medication.

Title: "ED Record Charting"
Purpose: To provide documentation of the Emergency Department patient from arrival to disposition.
1. Upon Patient's arrival to ED document the following:
D. Pain Level
E. Vital Signs