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Based on review of the medical record, staff interviews and document review it was revealed the facility failed to provide care in a safe setting and failed to ensure all labs in the emergency department (ED) were drawn at an appropriate time as per policy. This failure was identified in one (1) out of ten (10) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. Review of the medical record for patient #1 revealed patient #1 was seen in the ED on 5/5/21 with a diagnosis of bilateral pneumonia. Patient #1 was transported to the ED by ambulance. Patient #1 was documented as having altered mental status worsening for two days, prior to admission to the ED. The physician initiated the medical screening exam at 2:56 p.m. Lab orders were written at this time. Orders for lab were completed at 7:35 p.m. Patient #1 was triaged as acuity three (3) urgent. Patient #1 was admitted to the facility on 5/6/21.

2. An interview was conducted with Registered Nurse (RN) #1 on 6/8/21 at 9:28 a.m. When asked about labs for patient #1 being ordered at 2:56 p.m. and not being drawn until around 7:25 p.m., he stated the facility no longer has a phlebotomist come to the ED to draw labs, the nursing staff draw all labs. When shown the policy for lab draws, he stated he was unaware all STAT labs are to be drawn within fifteen (15) minutes. He stated every lab in the ED is considered a STAT lab. He stated ED nursing staff are responsible to draw all labs for patients seen in the ED.

3. A review of the policy titled "Pathology & Laboratory Testing Guidelines and Laboratory Testing Methodologies," approved 03/2021, stated in part: "a. STAT - These tests are entered into the computer system at priority "S" and means a critical situation exists. The lab will collect the specimen within 15 minutes ...."

4. An interview was conducted with the CNO on 6/8/21 at 2:56 p.m. She concurred the labs for patient #1 were not drawn until 7:39 p.m. and not completed as per policy. She concurred the nursing staff are to draw all labs in the ED.

Based on review of the medical record, staff interviews and document review it was revealed the emergency room nursing staff failed to provide care according to hospital policies and procedures. Nursing failed to ensure all labs in the emergency department (ED) were drawn at an appropriate time as per policy. This failure was identified in one (1) out of ten (10) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. Review of the medical record for patient #1 revealed patient #1 was seen in the ED on 5/5/21 with a diagnosis of bilateral pneumonia. Patient #1 was transported to the ED by ambulance. Patient #1 was documented as having altered mental status worsening for two days, prior to admission to the ED. The physician initiated the medical screening exam at 2:56 p.m. Lab orders were written at this time. Orders for lab were completed at 7:35 p.m. Patient #1 was triaged as acuity three (3) urgent. Patient #1 was admitted to the facility on 5/6/21.

2. An interview was conducted with Registered Nurse (RN) #1 on 6/8/21 at 9:28 a.m. When asked about labs for patient #1 being ordered at 2:56 p.m. and not being drawn until around 7:25 p.m., he stated the facility no longer has a phlebotomist come to the ED to draw labs, the nursing staff draw all labs. When shown the policy for lab draws, he stated he was unaware all STAT labs are to be drawn within fifteen (15) minutes. He stated every lab in the ED is considered a STAT lab. He stated ED nursing staff are responsible to draw all labs for patients seen in the ED.

3. A review of the policy titled "Pathology & Laboratory Testing Guidelines and Laboratory Testing Methodologies," approved 03/2021, stated in part: "a. STAT - These tests are entered into the computer system at priority "S" and means a critical situation exists. The lab will collect the specimen within 15 minutes ...."

4. An interview was conducted with the CNO on 6/8/21 at 2:56 p.m. She concurred the labs for patient #1 were not drawn until 7:39 p.m. and not completed as per policy. She concurred the nursing staff are to draw all labs in the ED.

Based on review of the medical record, staff interviews and document review it was revealed patient #1 did not receive care as per emergency room policies and procedures. The facility failed to ensure all labs in the emergency department (ED) were drawn at an appropriate time as per policy. This failure was identified in one (1) out of ten (10) medical records reviewed (patient #1). This failure has the potential to adversely affect all patients.

Findings include:

1. Review of the medical record for patient #1 revealed patient #1 was seen in the ED on 5/5/21 with a diagnosis of bilateral pneumonia. Patient #1 was transported to the ED by ambulance. Patient #1 was documented as having altered mental status worsening for two days, prior to admission to the ED. The physician initiated the medical screening exam at 2:56 p.m. Lab orders were written at this time. Orders for lab were completed at 7:35 p.m. Patient #1 was triaged as acuity three (3) urgent. Patient #1 was admitted to the facility on 5/6/21.

2. An interview was conducted with Registered Nurse (RN) #1 on 6/8/21 at 9:28 a.m. When asked about labs for patient #1 being ordered at 2:56 p.m. and not being drawn until around 7:25 p.m., he stated the facility no longer has a phlebotomist come to the ED to draw labs, the nursing staff draw all labs. When shown the policy for lab draws, he stated he was unaware all STAT labs are to be drawn within fifteen (15) minutes. He stated every lab in the ED is considered a STAT lab. He stated ED nursing staff are responsible to draw all labs for patients seen in the ED.

3. A review of the policy titled "Pathology & Laboratory Testing Guidelines and Laboratory Testing Methodologies," approved 03/2021, stated in part: "a. STAT - These tests are entered into the computer system at priority "S" and means a critical situation exists. The lab will collect the specimen within 15 minutes ...."

4. An interview was conducted with the CNO on 6/8/21 at 2:56 p.m. She concurred the labs for patient #1 were not drawn until 7:39 p.m. and not completed as per policy. She concurred the nursing staff are to draw all labs in the ED.