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Based on observation, and staff interview, it was determined the facility did not ensure maintenance of the equipment at an acceptable level of safety for the staff, patients, and visitors.

Findings:

During the tour of the main entrance of the facility on 10/27/2015, at 12:30 PM, the surveyor observed a low-voltage electrical wire running parallel to a water irrigation tubing on the surface of the ground and in close proximity to an artificially created pond.

The low voltage electrical wire, along with the water irrigation tubing was observed to be lying across a man-made pathway and therefore created risks for electrical shocks and other safety hazards.

Interview with the Director of Maintenance on 10/29/2015, at 9:00 AM, revealed that the low voltage electrical wire and the irrigation tubing must be placed underground in separate areas, to prevent tripping hazards on the surface of the ground, and electrical shocks in the water of the pond. The employee stated,"No, it is not proper; sure, will take care of it right now."

Based on document review and staff interview, in 5 of 10 medical records (MR) reviewed, it was determined that the facility did not follow its policies to ensure that all patients who presented to the emergency department; (a) are assessed in a timely manner, (b) treatments are initiated in a timely manner and (c) consultations are done as required (MRs # 1, 2, 5, 7 and 8).

Findings include:

(1) Review of MR #7 revealed this fifty-seven year old patient presented to the ED on July 8, 2015, at 10:12 AM, after he had collapsed while he was walking that morning. The documentation by the triage nurse states the patient was getting ready to jog when he became dizzy and collapsed. EMS was nearby and attended to the patient. The "patient became anxious in the ambulance pulling out IV access and becoming SOB" (short of breath). The documentation by the ED physician states, the patient arrived to the ED " talking with EMS and providers and nursing staff. When the patient was brought to the room however, he had a seizure." After the seizure activity the patient's heart rate went from 60 to 0.
The patient did not have a history of Seizure Disorder, but he had pre-existing medical history that included Gastric Bypass in May 2015, Cancer of the Prostate, Embolism and Thrombosis and Asthma.

It could not be determined the time that the patient's heart rate was 60 and the time that it decreased to 0. The medical record does not indicate the duration of the seizure activity, specifically when the seizure began and ended, as required with current standards of practice for documenting seizure activity.

Documentation by the nurse states, while the patient was in the hallway the patient began to have a seizure. The nurse documented that the patient was " hooked up to a monitor and began agonal breathing and the pulse began to slow." The patient developed asystole at 10:22 AM and he had agonal breathing. Chest compressions and resuscitative measures were initiated at this point. The patient expired at 10:42 AM that morning.

The documentation in the medical record identified that during the period of 10:12:45 to 10:17 AM; the patient was moved from room #12 which is a non-monitored bed, to the hallway, then returned to room #12, and at 10:24 AM, was transferred to room #16, which is a monitored bed.
There is no documentation to validate the monitoring that was provided to the patient during this period, prior to the patient being "hooked up to a monitor and began agonal breathing and the pulse began to slow."

(2) Review of MR #1 revealed this is twenty year old patient presented to the ED at 6:52 PM on September 2, 2015, after he had fallen in his bathroom and had an episode of loss of consciousness. Patient's sister states, she heard a "lot of banging and crashing" and when she tried to open the bathroom door it was blocked with the patient's body. After the patient woke up he felt weak, lethargic, was confused and vomited. The EMS report states the patient's B/P 88/60 and he had excessive diaphoresis, was very lethargic and had an ashen color; EMS initiated oxygen treatment and intravenous fluids. The patient had a history of Bipolar Disorder and Depression. The physician's review of systems revealed the patient had mild scalp erythema; history of fatigue, seizure and weakness.

The "Morse Fall Risk " assessment for this patient was incomplete and only one question was answered; a fall risk protocol was not initiated, seizure precautions were not implemented.

The sepsis screen inaccurately indicates the patient did not have a history of acutely altered mental state or change in mental status, however, the sister reported that the patient had an episode of loss of consciousness.

The physician wrote an order for oxygen to be administered, however the order was incomplete and did not indicate the amount and rate of oxygen administration and there was no documentation that oxygen was administered to the patient.
The physician also wrote an order for an EKG and there was no documentation that the EKG was done.

There was no documentation that the nursing staff performed a reassessment of the patient after the initial assessment, as required by the facility's policy.

Review of the facility's policy titled "Assessments of Patients in the Emergency Department," which was last reviewed in 4/15 states, "Reassessments are performed on each patient at a minimum of every 2 hours or sooner." This patient was a triage level II, had a loss of consciousness and he was in the ED for more than 3 hours.

There was no GCS (Glasgow Coma Scale) score (to assess the patient's level of consciousness following the reported fall with episode of loss of consciousness), throughout his stay in the ED.

There was an order for a neurology consultation but there is no documentation that this was done. The ED physician also noted "In the ED, Patient with seizure activity." It could not be determined whether the patient had another episode of seizure activity while he was in the ED because the nurse's notes did not reflect this episode.

There is no documentation that The ED physician performed a neurology reassessment throughout the patient's stay in the ED. Documentation states the patient was given discharge instructions at 10:29 PM that night, with a discharge diagnosis of Convulsions.

During interview on October 27, 2015, at 11:35 AM, The Director of the ED stated that a "discussion" with the on-call neurologist was done, that a neurology consultation may not have been necessary and that he concluded that the care was appropriate.

(3) Review of MR #5 revealed this eighty year old patient presented to the ED on September 12, 2015 at 3:57 PM, after he had fallen that day. At 4:03 PM the patient was unconscious, in respiratory distress and he had a heart rate of 83 and a B/P of 152/83. The GCS score was 3, which is abnormal. There was no documentation of a respiratory rate or oxygen saturation. The patient was intubated at 4:10 PM and attached to a ventilator. A CT-Scan of the head and face showed the patient had extensive subarachnoid and intraventricular bleed and left orbital and left nasal fractures. The neurosurgeon was paged at 4:20 PM and she returned the call 5 minutes later.
The record contained an entry at 7:47 PM that night which indicated the patient's condition was "dismal." The ED physician documented that "multiple re-evaluations " were done but the results of these re-evaluations were not documented.

There was no documented evidence that the neurosurgeon saw the patient and performed a physical assessment, and her notes were "incomplete."


(4) Review of MR #2 revealed this is sixty-two year old patient presented to the ED on October 25, 2015, 12:12 AM, with a complaint of left sided chest pain which had radiated to her shoulder and which had hurt when she breathed. The patient's pain score was 6 on a scale of zero (0), no pain to 10, worst pain. The patient had a previous medical history of Chronic Obstructive Pulmonary Disease, Depression and Non-Hodgkin's Lymphoma. An EKG was done at 12:21 AM which showed the patient had a "sinus rhythm with premature ventricular complexes, possible anterior infarct 1/5/15, premature supraventricular tachycardia now present."

There was no documentation to indicate that this EKG was reported to the doctor or that the other protocols for chest pain were initiated. There was no documented evidence that the patient was placed in a bed or attached to a continuous cardiac monitor. The patient left from the waiting area at 12:46 AM that morning without been seen by a physician or medical practitioner.

The policy titled "Chest Pain Guidelines," which was last revised 12/08 states, "the patient is placed in the first available appropriate patient care area. The triage RN will notify the charge RN of the patient and document this notification in the nurse's notes." The policy also states, "Follow advanced Triage Protocols, including: Labs, CXR, EKG to MD stat, O2 2-3 L via N/C, Saline Lock, pulse ox, cardiac monitor. Consider Aspirin, Beta Blockers and Pain Management."
There was no documented evidence that any portion of this protocol was implemented.


(5) Patient MR# 8, presented to the ED on March 13, 2015 at 8:45 PM, with a complaint of epigastric pain radiating to his chest, nausea and vomiting. The patient did not have a previous medical history but he had a history of drinking alcohol. The pain was sharp, acute and shooting and it was scored at 9 on a scale of zero (0) to 10. The patient was medicated with Zofran and Protonix and IV fluids were administered. At 3:00 AM, the physician documented that the patient's chest pain was returning and decided that the patient should be admitted.
The nurse did not reassess the patient's pain score until 7:45 AM, almost 12 hours after his arrival and at this point the pain was still elevated at 8 on a scale of 10. There were no further re-assessments of the pain score. The patient remained in the ED for more than twenty (20) hours before signing out against medical advice at 3:49 PM, on March 14, 2015.


All findings in the medical records were witnessed by the ED Lead Clinical Analyst, on October 26, 27 and 29, 2015.