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Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to ensure patients are monitored by nurses in the Emergency Department (ED) according to facility policy. (Patient (P)1).

Findings include:

Facility policy titled, "Documentation in the Emergency Department: Guidelines," last revised January 2023, states, " ...V. Procedure: A ...3. The nursing documentation will include an initial set of vital signs, reassessment of the vital signs and patient condition as per patient acuity, and a final set of vital signs within one hour of discharge ...C. Reassessments (including a complete set of vital signs) shall be performed as often as is required by the patient's condition, but at least every two hours with the findings documented.

On 3/11/2025 at 10:04 AM, P1's medical record was reviewed with Staff (S) 2, Director of ED Services. The medical record revealed the following:

On 2/27/25 at 8:52 AM, P1 presented alone to the ED with a chief complaint of "sore on chest."
At 8:57 AM, P1 had an initial assessment completed by the triage nurse. Vital signs were taken at this time.
At 9:58 AM, S19, P1's primary nurse, performed a reassessment.
At 12:00 PM, P1's vital signs were taken.
At 12:25 PM, P1's vital signs were taken.
At 1:23 PM, P1 left against medical advice (AMA).

On 3/11/25 at 1:34 PM, when asked how frequently neurological assessments must be completed on patients, S2 reported that all patients should be assessed every 2 hours. According to S2, since both the nurse and doctor were working the substance use route for P1, more frequent assessments were not indicated. S2 confirmed there were no nursing reassessments for P1 after 9:58 AM. S2 confirmed that reassessments should have been completed every 2 hours until an admission or transfer order was placed. Then the assessments would be completed based on the level of care ordered (such as Intensive Care Unit (ICU) or telemetry). S2 also confirmed that P1's vital signs were not taken every 2 hours as the policy dictates.

Based on medical record review, staff interview, and review of facility documents, it was determined the facility failed to maintain accurate medical records, in two of 20 medical records reviewed (Patients (P) 1 and P6).

Findings include:

Facility policy for Medical Staff Services titled, "Medical Record Documentation," last revised December 2024, states, " ...IV. Policy ...4. Medical Record Entries ...b. All medical record entries are to be promptly completed, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the services provided ..."

On 3/11/2025 at 10:04 AM, P1's medical record was reviewed with Staff (S) 2, Director of Emergency Department (ED) Services. The medical record revealed the following:

On 2/27/25 at 9:09 AM, P1 was seen by S18, ED Provider. The ED physician note was electronically signed by S18 on 3/4/25 at 8:11AM.

On 3/11/25 at 11:16 AM, an interview was conducted with S18. S18 was shown the nursing note which indicated that P1 had a change in mental status, and asked S18 to clarify if his/her own note reassessed P1's neurological status. According to S18, his/her note states P1 was stable for discharge. When asked what time this assessment was completed, S18 stated that his/her note is a rolling note, and there is an internal timestamp in the electronic medical record (EMR). S18 stated the Informatics team could get the timestamps of his/her documentation.

At the conclusion of the interview with S18, S2 was asked to retrieve timestamps for each entry in S18's ED physician note in P1's medical record. He/she contacted the Informatics team to determine if this information could be obtained.

On 3/11/25 at 1:45 PM, S2 reported that the video recordings from the Electronic Medical Record (EMR) that could reveal documentation timestamps could only be done within 7 days of charting. S2 explained they were out of the window for timestamp retrieval for this medical record, including the ED physician note by S18.


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On 3/11/2025 at 1:00PM, P6's medical record was reviewed and revealed the following:

On 11/3/2024 at 7:59 AM, an ED Physician note completed by S18 states, " ... Reexamination/Reevaluation: [P22's name] 21 Years F [female] DOB [Date of Birth]: 04/02/2003..."

The name, age, and DOB documented in P6's medical record belonged to P22.

On 3/11/2025 at 1:10 PM, when asked why P22's name, age, and DOB was documented in P6's medical record, S1, ED Nurse Manager, stated, "I am not sure. That should not be in this chart, that is very strange."

Based on observation and staff interview, it was determined the facility failed to ensure a defect-free environment is maintained for patients, staff, and the general public.

Findings include:

During a building tour conducted at 11:00 AM on 3/11/25, with Staff (S)17, Facility Manager, the following were noted:

Two (2) open windows in the emergency department waiting room did not have insect screens. The lack of window screens would allow for the intrusion of insects and/or vermin into the building.

The delayed egress lock mechanism on the ambulance bay doors was broken, permitting unsupervised entering and exiting to and from the emergency department treatment area.

The above was confirmed by S17 upon discovery.