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Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.23 NURSING SERVICES was out of compliance.

A-0395 - A registered nurse must supervise and evaluate the nursing care for each patient. The facility failed to monitor patients' vital signs in accordance with facility expectations. This failure resulted in patients returning to the facility or to separately certified facilities within 72 hours with similar medical conditions requiring additional treatment.

Based on the manner and degree of the standard level deficiency referenced to the Condition, it was determined the Condition of Participation §482.55 EMERGENCY SERVICES was out of compliance.

A-1112 There must be adequate medical and nursing personnel qualified in emergency care to meet the written emergency procedures and needs anticipated by the facility. The facility failed to ensure patients were treated in accordance with written emergency procedures and stable prior to discharging home. In addition, the facility failed to ensure emergency medical needs were met in accordance with written emergency procedures of patients presenting to the emergency department (ED) with a chief complaint of a nosebleed. These failures resulted in patients returning to the facility or to separately certified facilities within 72 hours with similar medical conditions requiring additional treatment.

Based on interviews and document review, the facility failed to monitor patients' vital signs in accordance with facility expectations in 16 of 23 (Patients #1, #2, #3, #4, #5, #9, #10, #11, #12, #13, #14, #16, #17, #20, #21, and #22) medical records reviewed of patients receiving care in the Emergency Department (ED). This failure resulted in patients returning to the facility or to separately certified facilities within 72 hours with similar medical conditions requiring additional treatment.

Findings include:

Facility Policy:

The policy Vitals Signs - Taking & Recording read all patients admitted to the ED would have a baseline set of vital signs completed at the time of triage and at discharge. Baseline vitals signs would include temperature, pulse, respirations, and blood pressure. Patients who remain in the ED for extended periods of time would have vital signs re-assessed and documented at least every two hours. Every patient would have vital signs taken and recorded upon discharge from the ED, unless all vital signs were within normal limits at triage and the length of stay was less than 90 minutes.

The policy Discharge Planning & Discharge of the Emergency Department Patient read patients would be discharged from the ED after their condition had been evaluated, treated and the ED physician had directed the discharge plan. Prior to actual discharge, vital signs would be re-evaluated and documented.

The policy Rapid Medical Examination (RME) read discharge vitals would be completed on all RME patients within 30 minutes of discharge.

References:

According to the Hospital Scope of Service, the ED provided services including cardiac and a wide scope of treatments for minor illness/injury. All patients of the ED would be assessed on arrival and assigned a priority/severity score. The patient was assessed again once in the room, after each intervention and then at least hourly by a Registered Nurse (RN) until discharge, admission, or transfer.

1. The facility failed to ensure a complete set of vital signs was taken upon arrival to the Emergency Department (ED) and that vital signs were reassessed before patients were discharged.

a. A review of the medical record for Patient #10 revealed she was brought by ambulance to the ED on 12/11/17 at 1:56 p.m. after a motor vehicle accident. The patient told hospital staff she had crashed her car into a ditch, but she had no recollection of how the accident occurred. At 2:01 p.m., the Patient's vital signs were taken. Patient #10 had an elevated blood pressure of 169/85. Her other vital signs (heart rate, respiratory rate, and oxygen saturation) were within normal limits; however, a temperature was not taken.

Nurse Practitioner (NP) #7 documented she was suspicious Patient #10's loss of consciousness may have been related to a seizure disorder of which the patient had a past history of. The patient was instructed not to drive, to see her primary care provider, and was then discharged home the same afternoon at 4:22 p.m. The medical record did not contain any additional vital signs taken during this ED visit.

At 5:32 p.m., just over an hour later, Patient #10 returned to the ED by ambulance after she had another seizure at home. Patient #10 then had another seizure while she was evaluated in the ED. A set of vital signs was taken at 5:33 p.m., which revealed an elevated blood pressure of 177/84. Again, no temperature was documented. At 6:15 p.m., Patient #10's respiratory rate was elevated at 30 breaths-per-minute; still, no temperature was documented. At 7:46 p.m., another set of vital signs was taken, and included a temperature of 101.4 degrees Fahrenheit (F). According to the ED Course documentation, Physician #8 became aware Patient #10 had a fever at 7:52 p.m. and was concerned the patient may have had meningitis (inflammation or infection of the brain and spinal cord). At 9:27 p.m., the Patient was transferred for continued medical care to another facility.

b. Review of the medical record for Patient #22 revealed a 92 year old woman was brought to the ER by ambulance on 12/18/17 at 12:39 p.m. after she sustained a fall. Patient #22 had a set of vital signs taken at 12:52 p.m. An elevated blood pressure of 214/87 was recorded. Another blood pressure reading was recorded four minutes later, also at 214/87. Patient #22 was discharged two hours later at 2:52 p.m. No further blood pressures were taken during this ED visit.

The following day, 12/19/17 at 6:19 p.m., Patient #22 was returned to the ED by ambulance after being observed with a blank stare, right facial droop, and garbled speech. After testing, Patient # 22 was diagnosed with a Transient Ischemic Attack (TIA), or mini-stroke, ST-Elevation Myocardial Infarction (STEMI), or heart attack, and an internal carotid artery occlusion (blockage). At 9:21 p.m., Patient #22 was transferred by helicopter to another hospital for a higher level of care.

c. A review of Patient #3's medical record revealed the patient presented to the ED at 6:45 p.m. on 10/10/17 with a chief complaint of a nosebleed. According to the ED Provider Notes, Nurse Practitioner (NP) #4 documented the patient stated his nose started bleeding in the morning at about 8:30 a.m. after he blew his nose and that it had been trickling off and on all day. NP #4 further documented Patient #3 was taking an antiplatelet medication which was prescribed after a cardiac stent was placed 3 weeks prior to arrival to the ED.

Triage vitals were taken at 6:49 p.m. and revealed a blood pressure of 85/56 and an oxygen saturation level of 86%. At 7:53 p.m., ED Course documentation reported tissue packing was removed from the left nares and 2 sprays of Afrin nasal spray was administered.

Nursing documentation revealed at 8:06 p.m. Patient #3 was in the process of being discharged when he had started having a nosebleed again. Patient #3 was subsequently discharged home at 8:40 p.m. There was no documentation in the medical record showing if the low blood pressure and oxygen saturation level were addressed and reassessed.

According to the Multiple ED Visits report, Patient #3 presented to a separately certified facility the following morning, 10/11/17 at 9:42 a.m., and was admitted with a diagnosis of acute renal failure.

A patient grievance report filed on 11/1/17 reported Patient #3 required 2 units of blood to be transfused after presenting to the separately certified facility with a nosebleed and was admitted for 2 days.

Similar findings of no documentation that a complete set of vital signs was taken upon admission or that vital signs were reassessed prior to discharge were found during medical record reviews of Patients #1, #2, #4, #5, #9, #11, #12, #13, #14, #16, #17, #20, and #21.

d. On 2/1/18 at 4:36 p.m., an interview was conducted with ED Registered Nurse (RN) #2. She stated it was the primary nurse's responsibility to obtain vital signs for patients. RN #2 stated all patients were expected to have vital signs taken prior to discharge. RN #2 further stated if patients were found to have abnormal vital signs, such as an oxygen saturation level of 86%, she would reassess the patient and notify the provider of the abnormal results.

e. On 2/2/18 at 11:33 a.m., an interview was conducted with Critical Care and ED Manager (Manager) #3, who stated her expectation was that vital signs should be taken in the ED according to the facility policy. Manager #3 stated this included upon admission and then repeated based on patient acuity and whether the initial vital signs were normal or abnormal. She stated vital signs were also expected for all patients within 30 minutes of discharge.

Manager #3 said she was not aware of a pattern of vital signs not being completed upon presentation to the ED or prior to discharge. Manager #3 further stated she had not been conducting any audits to ensure vital signs were complete in patients' medical records.

f. An interview was conducted on 2/7/18 at 3:14 p.m. with the Chief Nursing Officer (CNO) #9. CNO #9 stated he expected nurses to take vital signs during the initial triage process. He stated patients absolutely needed to have had their temperatures taken. CNO #9 stated nurses needed to ensure the last set of vital signs was taken within 30 minutes of discharge. CNO #9 stated reassessing vital signs was important to ensure the patient left the hospital in a condition safe to be discharged.

CNO #9 then explained the process of auditing patients' medical records. CNO #9 stated audits of patient care were initiated if an issue was identified, such as a fall, or if a nurse self-referred a patient's visit to be reviewed. If trends of issues were identified during the auditing process, feedback would be provided to the nursing staff. CNO #9 then stated he was not aware of the issue of vital signs not being completed upon presentation to the ED or prior to discharge.

g. On 2/7/18 at 10:44 a.m., an interview was conducted with ED Physician (Physician #5), who stated he expected patients to have vital signs taken upon arrival and discharge. Physician #5 stated during his shift the prior night he was unable to find a temperature recorded in a patient's medical record and had to ask the staff to record the vital sign.

Physician #5 reviewed the medical record for Patient #10 from 12/11/17 at 1:56 p.m. Physician #5 was not able to locate a temperature reading in the medical record. He stated if the temperature was there on the first visit, it may have changed his course of treatment. Physician #5 stated the patient's temperature should have been taken.

Physician #5 also reviewed the medical records for Patient #22 from 12/18/17 and 12/19/17. Physician #5 confirmed there were two blood pressure readings documented 4 minutes apart at 12:52 p.m. and 12:56 p.m. Both readings were 214/87. He stated no other blood pressure readings were recorded in Patient #22's medical record. Physician #5 stated if he thought the Patient was having a stroke, a blood pressure of 214/87 would have concerned him. Physician #5 stated he would have wanted to have another blood pressure reading for Patient #22 in order to evaluate the Patient's condition and see how the Patient's blood pressure was trending.

Based on interviews and document review, the facility failed to ensure patients were treated in accordance with written emergency procedures and stable prior to discharging home in 16 of 23 (Patients #1, #2, #3, #4, #5, #9, #10, #11, #12, #13, #14, #16, #17, #20, #21, and #22) medical records reviewed of patients receiving care in the Emergency Department (ED). In addition, the facility failed to ensure emergency medical needs were met in accordance with written emergency procedures in 1 of 4 medical records reviewed of patients presenting to the emergency department (ED) with a chief complaint of a nosebleed (Patient #3). These failures resulted in patients returning to the facility or to separately certified facilities within 72 hours with similar medical conditions requiring additional treatment.

Findings include:

Facility Policy:

The policy Vitals Signs - Taking & Recording read all patients admitted to the ED would have a baseline set of vital signs completed at the time of triage and at discharge. Baseline vitals signs would include temperature, pulse, respirations, and blood pressure. Patients who remain in the ED for extended periods of time would have vital signs re-assessed and documented at least every two hours. Every patient would have vital signs taken and recorded upon discharge from the ED, unless all vital signs were within normal limits at triage and the length of stay was less than 90 minutes.

The policy Discharge Planning & Discharge of the Emergency Department Patient read patients would be discharged from the ED after their condition had been evaluated, treated and the ED physician had directed the discharge plan. Prior to actual discharge, vital signs would be re-evaluated and documented.

The policy Rapid Medical Examination (RME) read discharge vitals would be completed on all RME patients within 30 minutes of discharge.

References:

According to the Hospital Scope of Service, the ED provided services including cardiac and a wide scope of treatments for minor illness/injury. All patients of the ED would be assessed on arrival and assigned a priority/severity score. The patient was assessed again once in the room, after each intervention and then at least hourly by a Registered Nurse (RN) until discharge, admission, or transfer.

1. The facility failed to ensure a complete set of vital signs was taken upon arrival to the Emergency Department (ED) and that vital signs were reassessed before patients were discharged.

a. A review of the medical record for Patient #10 revealed she was brought by ambulance to the ED on 12/11/17 at 1:56 p.m. after a motor vehicle accident. The patient told hospital staff she had crashed her car into a ditch, but she had no recollection of how the accident occurred. At 2:01 p.m., the Patient's vital signs were taken. Patient #10 had an elevated blood pressure of 169/85. Her other vital signs (heart rate, respiratory rate, and oxygen saturation) were within normal limits; however, a temperature was not taken.

Nurse Practitioner (NP) #7 documented she was suspicious Patient #10's loss of consciousness may have been related to a seizure disorder of which the patient had a past history of. The patient was instructed not to drive, to see her primary care provider, and was then discharged home the same afternoon at 4:22 p.m. The medical record did not contain any additional vital signs taken during this ED visit.

At 5:32 p.m., just over an hour later, Patient #10 returned to the ED by ambulance after she had another seizure at home. Patient #10 then had another seizure while she was evaluated in the ED. A set of vital signs was taken at 5:33 p.m., which revealed an elevated blood pressure of 177/84. Again, no temperature was documented. At 6:15 p.m., Patient #10's respiratory rate was elevated at 30 breaths-per-minute; still, no temperature was documented. At 7:46 p.m., another set of vital signs was taken, and included a temperature of 101.4 degrees Fahrenheit (F). According to the ED Course documentation, Physician #8 became aware Patient #10 had a fever at 7:52 p.m. and was concerned the patient may have had meningitis (inflammation or infection of the brain and spinal cord). At 9:27 p.m., the Patient was transferred for continued medical care to another facility.

b. Review of the medical record for Patient #22 revealed a 92 year old woman was brought to the ER by ambulance on 12/18/17 at 12:39 p.m. after she sustained a fall. Patient #22 had a set of vital signs taken at 12:52 p.m. An elevated blood pressure of 214/87 was recorded. Another blood pressure reading was recorded four minutes later, also at 214/87. Patient #22 was discharged two hours later at 2:52 p.m. No further blood pressures were taken during this ED visit.

The following day, 12/19/17 at 6:19 p.m., Patient #22 was returned to the ED by ambulance after being observed with a blank stare, right facial droop, and garbled speech. After testing, Patient # 22 was diagnosed with a Transient Ischemic Attack (TIA), or mini-stroke, ST-Elevation Myocardial Infarction (STEMI), or heart attack, and an internal carotid artery occlusion (blockage). At 9:21 p.m., Patient #22 was transferred by helicopter to another hospital for a higher level of care.

c. A review of Patient #3's medical record revealed the patient presented to the ED at 6:45 p.m. on 10/10/17 with a chief complaint of a nosebleed. According to the ED Provider Notes, Nurse Practitioner (NP) #4 documented the patient stated his nose started bleeding in the morning at about 8:30 a.m. after he blew his nose and that it had been trickling off and on all day. NP #4 further documented Patient #3 was taking an antiplatelet medication which was prescribed after a cardiac stent was placed 3 weeks prior to arrival to the ED.

Triage vitals were taken at 6:49 p.m. and revealed a blood pressure of 85/56 and an oxygen saturation level of 86%. At 7:53 p.m., ED Course documentation reported tissue packing was removed from the left nares and 2 sprays of Afrin nasal spray was administered.

Nursing documentation revealed at 8:06 p.m. Patient #3 was in the process of being discharged when he had started having a nosebleed again. Patient #3 was subsequently discharged home at 8:40 p.m. There was no documentation in the medical record showing if the low blood pressure and oxygen saturation level were addressed and reassessed.

According to the Multiple ED Visits report, Patient #3 presented to a separately certified facility the following morning, 10/11/17 at 9:42 a.m., and was admitted with a diagnosis of acute renal failure.

A patient grievance report filed on 11/1/17 reported Patient #3 required 2 units of blood to be transfused after presenting to the separately certified facility with a nosebleed and was admitted for 2 days.

Similar findings of no documentation that a complete set of vital signs was taken upon admission or that vital signs were reassessed prior to discharge were found during medical record reviews of Patients #1, #2, #4, #5, #9, #11, #12, #13, #14, #16, #17, #20, and #21.

d. On 2/1/18 at 4:36 p.m., an interview was conducted with ED Registered Nurse (RN) #2. She stated it was the primary nurse's responsibility to obtain vital signs for patients. RN #2 stated all patients were expected to have vital signs taken prior to discharge. RN #2 further stated if patients were found to have abnormal vital signs, such as an oxygen saturation level of 86%, she would reassess the patient and notify the provider of the abnormal results.

e. On 2/2/18 at 11:33 a.m., an interview was conducted with Critical Care and ED Manager (Manager) #3, who stated her expectation was that vital signs should be taken in the ED according to the facility policy. Manager #3 stated this included upon admission and then repeated based on patient acuity and whether the initial vital signs were normal or abnormal. She stated vital signs were also expected for all patients within 30 minutes of discharge.

Manager #3 said she was not aware of a pattern of vital signs not being completed upon presentation to the ED or prior to discharge. Manager #3 further stated she had not been conducting any audits to ensure vital signs were complete in patients' medical records.

f. An interview was conducted on 2/7/18 at 3:14 p.m. with the Chief Nursing Officer (CNO) #9. CNO #9 stated he expected nurses to take vital signs during the initial triage process. He stated patients absolutely needed to have had their temperatures taken. CNO #9 stated nurses needed to ensure the last set of vital signs was taken within 30 minutes of discharge. CNO #9 stated reassessing vital signs was important to ensure the patient left the hospital in a condition safe to be discharged.

CNO #9 then explained the process of auditing patients' medical records. CNO #9 stated audits of patient care were initiated if an issue was identified, such as a fall, or if a nurse self-referred a patient's visit to be reviewed. If trends of issues were identified during the auditing process, feedback would be provided to the nursing staff. CNO #9 then stated he was not aware of the issue of vital signs not being completed upon presentation to the ED or prior to discharge.

g. On 2/7/18 at 10:44 a.m., an interview was conducted with ED Physician (Physician #5), who stated he expected patients to have vital signs taken upon arrival and discharge. Physician #5 stated during his shift the prior night he was unable to find a temperature recorded in a patient's medical record and had to ask the staff to record the vital sign.

Physician #5 reviewed the medical record for Patient #10 from 12/11/17 at 1:56 p.m. Physician #5 was not able to locate a temperature reading in the medical record. He stated if the temperature was there on the first visit, it may have changed his course of treatment. Physician #5 stated the Patient's temperature should have been taken.

Physician #5 also reviewed the medical records for Patient #22 from 12/18/17 and 12/19/17. Physician #5 confirmed there were two blood pressure readings documented 4 minutes apart at 12:52 p.m. and 12:56 p.m. Both readings were 214/87. He stated no other blood pressure readings were recorded in Patient #22's medical record. Physician #5 stated if he thought the Patient was having a stroke, a blood pressure of 214/87 would have concerned him. Physician #5 stated he would have wanted to have another blood pressure reading for Patient #22 in order to evaluate the Patient's condition and see how the patient's blood pressure was trending.

2. The facility failed to determine if Patient #3's presenting symptoms and condition were stabilized before discharging the patient home.

a. A review of Patient #3's medical record revealed the patient presented to the ED at 6:45 p.m. on 10/10/17 with a chief complaint of a nosebleed. According to the ED Provider Notes, Nurse Practitioner (NP) #4 documented the patient stated his nose started bleeding in the morning at about 8:30 a.m. after he blew his nose and that it had been trickling off and on all day. NP #4 further documented Patient #3 was taking an antiplatelet medication which was prescribed after a cardiac stent was placed 3 weeks prior to arrival to the ED.

Triage vitals were taken at 6:49 p.m. and revealed a blood pressure of 85/56 and an oxygen saturation level of 86%. At 7:53 p.m., ED Course documentation reported tissue packing was removed from the left nares and 2 sprays of Afrin nasal spray was administered.

Nursing documentation revealed at 8:06 p.m. Patient #3 was in the process of being discharged when he had started having a nosebleed again. Patient #3 was subsequently discharged home at 8:40 p.m. There was no documentation in the medical record showing if labs were drawn to assess if Patient #3 had lost a significant amount of blood or that the low blood pressure and oxygen saturation level were addressed and reassessed.

According to the Multiple ED Visits report, Patient #3 presented to a separately certified facility the following morning, 10/11/17 at 9:42 a.m., and was admitted with a diagnosis of acute renal failure.

A patient grievance report filed on 11/1/17 reported Patient #3 required 2 units of blood to be transfused after presenting to the separately certified facility with a nosebleed and was admitted for 2 days.

b. Registered Nurse (RN) #2 was interviewed on 2/1/18 at 4:36 p.m. who explained the typical process with providing care to patients presenting to the ED with nosebleeds. RN #2 stated an initial priority assessment for patients with nosebleeds included assessing their blood pressure to see if they were low, which could indicate excessive blood loss. In addition, common practice for treating patients with nosebleeds included obtaining blood lab work to see if the patient's blood loss was significant. RN #2 stated an order from the physician or licensed independent practitioner (LIP) was required before labs could be drawn on a patient. RN #2 then stated a full set of vital signs was expected to be assessed prior to the patient's discharge.

c. The Critical Care Manager of the ED (Manager #3) was interviewed on 2/2/18 at 11:33 a.m. who stated her expectation was that vital signs should be taken in the ED according to the facility policy. Manager #3 stated this included upon admission and then repeated based on patient acuity and whether the initial vital signs were normal. She said vital signs were expected to be done on all patients within 30 minutes of discharge. Manager #3 reported she was not currently conducting medical record audits to see if staff was following the expectations in the facility policy regarding frequency of assessing vital signs because she was unaware that there was an issue until the present time.

Manager #3 stated she reviewed Patient #3's medical record and confirmed the patient was not re-assessed after abnormal vital signs were documented. Manager #3 said she recalled counseling the specific nurses involved with the patient's care but was unable to provide documentation of who was counseled, when the counseling occurred or what was discussed during the counseling. Manager #3 further stated she was not doing medical record reviews to assess whether or not other patients were lacking reassessments of vital signs in accordance with the facility's expectation.

Manager #3 then explained that initiating lab work was ultimately the responsibility or the provider although nursing staff could have voiced their concerns to the provider about the Patient #3's amount of bleeding and low blood pressure. Manager #3 stated there was no evidence showing if nursing staff notified the provider of these concerns during Patient #3's ED visit.

d. Nurse Practitioner (NP) #4 was interviewed on 2/1/18 at 3:29 p.m. who recalled providing care for Patient #3. NP #4 stated the patient reported to her that his nose had been trickling with blood throughout the day. According to NP #4, Patient #3's treatment course consisted of clamping his nose for a period of time and administering a nasal spray. NP #4 recalled after taking off the clamp the patient began bleeding again and the clamp was re-applied and monitored for an additional amount of time. Patient #3 was then discharged home.

After reviewing Patient #3's medical record, NP #4 said she was surprised that a complete blood count (CBC) lab level was not drawn to see if Patient #3 lost enough blood to be considered anemic and require a blood transfusion. NP #4 stated Patient #3 would have been a good candidate to assess a CBC on due to the patient's anticoagulation therapy and recent cardiac history. NP #4 said she was unsure of why Patient #3 did not have a CBC performed.

NP #4 confirmed that Patient #3's blood pressure of 85/56 and oxygen saturation level of 86% were on the low side. NP #4 said she would have expected the blood pressure and oxygen saturation levels to be reassessed prior to the patient being discharged. NP #4 stated she was unsure of why a reassessment had not occurred.

NP #4 stated she was not aware of any incident or grievance filed regarding the care of Patient #3. NP #4 further stated that she had not received any feedback or education after Patient #3's visit to the ED but that she would have appreciated any feedback offered.

e. Physician #5 was interviewed on 2/7/18 at 10:44 a.m. who stated he provided patient care in the ED as well as sharing responsibilities with the Medical Director of the ED. After reviewing Patient #3's medical record, Physician #5 confirmed that a CBC had not been done and the abnormal blood pressure and oxygen saturation levels were not reassessed prior to the patient's discharge. Physician #5 stated if a patient with a bloody nose was on anticoagulation therapy and had a low blood pressure, it would be expected to draw labs for further assessment of blood levels.

Physician #5 stated the care of Patient #3 was discussed in a peer review meeting after the facility became aware of Patient #3's subsequent visit at a separately certified facility for further treatment. Physician #5 further stated NP #4 was counseled after the review of Patient #3's care was completed; however, Physician #5 was unable to provide documentation of the counseling.

f. Physician #1 was interviewed on 2/2/18 at 12:22 p.m. and confirmed that he was the Medical Director of the ED. Physician #1 said he was familiar with Patient #3's visit and revealed the facility conducted a peer review on the patient's care. According to Physician #1, the conclusion of the peer review resulted in educating NP #4 with areas of care that were missed and on opportunities for improvement. This was in contrast to NP #4's prior interview where she did not recollect knowledge of the outcomes of Patient #3's care. Physician #1 further stated there were no other interventions put into place from the peer review of Patient #3's visit nor was there any documentation of NP #4's education.