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Based on record review and interview, the hospital failed to ensure a nurse supervised and evaluated the nursing care for each patient. This deficient practice is evidenced by:
1. Failure to assess 1 (#17) of 20 (#1-#16, #18-#20) patients' response to pain following an intervention.
2. Failure to reassess 1 (#12) of 20 (#1-#11, #13-#20) patients' vital signs at a minimum every 2 hours per policy.
3. Failure to reassess 1 (#8) of 20 (#1-#7, #9-#20) patients' vital signs within 30 minutes of discharge from emergency department per policy.
4. Failure to document a reassessment 1 (#7) of 20 (#1-#6, #8-#20) patients' per policy.
Findings:

Review of hospital policy revised 04/2024 titled "Emergency Department Roles, Assessments, Required Documentation Guidelines" revealed in part: Roles and Responsibilities 2. Bedside Nurse ix. Documentation of Interventions and Patient Contacts 2. Pain Assessment and Reassessment a. 1 HR PO b. 30 min IV or IM. Xi. Ongoing Vital Signs related to ESI, Patient Status, Medication, and procedures. The following are minimums without change in status or medications being administers. Nurses should assess and validate vitals based on treatment and patient condition. 1. ESI Level 1-2 = Vitals @ least every hour 2. ESI Level 3 = Vital @ least every 2 hours 3. ESI 4-5 = Vital @ least every 4 hours 4. Vitals within 30 minutes of discharge. j. Maintain appropriate documentation and ongoing assessment related to restraints and psychiatric patients.

1. Failure to assess 1 (#17) of 20 (#1-#16, #18-#20) patients' response to pain following an intervention.
Review of Patient #17 electronic medical record revealed the last blood pressure was documented on 05/04/2024 at 5:19 p.m. Patient received IV Morphine at 7:26 p.m. and had a pain assessment documented as 7/10. The patient was discharged at 8:39 p.m. on 05/04/2024. Further review revealed no reassessment of Blood Pressure which is not within the 2 hour minimum per policy or within 30 minutes of discharge per policy. There was also not a pain reassessment within 30 minutes of receiving IV pain medication as per policy.

In an interview on 05/15/2024 at 12:30 p.m. S1DED confirmed the above mentioned findings.

2. Failure to reassess 1 (#12) of 20 (#1-#11, #13-#20) patients' vital signs at a minimum every 2 hours per policy.
Review of Patient #12 electronic medical record revealed the last set of vital signs were documented on 04/24/2024 at 4:33 p.m. This patient was discharge at 7:13 p.m. on 04/24/2024. Further review revealed no reassessment of vital signs within the 2 hour minimum per policy or within 30 minutes of discharge per policy.

In an interview on 05/15/2024 at 11:00 p.m. S1DED confirmed the above mentioned findings.


3. Failure to reassess 1 (#8) of 20 (#1-#7, #9-#20) patients' vital signs within 30 minutes of discharge from emergency department per policy.
Review of Patient #8 electronic medical record revealed the patient received PO Ibuprofen at 1:02 p.m. and had a pain assessment documented as 5/10. The patient was discharged at 2:17 p.m. on 03/26/2024. Further review revealed there was no pain reassessment within 1 hour of receiving a PO pain medication as per policy.

In an interview on 05/15/2024 at 9:40 a.m. S1DED confirmed the above mentioned findings.

4. Failure to document a reassessment 1 (#7) of 20 (#1-#6, #8-#20) patients' per policy.
Review of Patient #7 electronic medical record revealed the patient received PO Norco at 3:05 p.m. and had a pain assessment documented as 10/10. The patient was discharged at 3:33 p.m. on 03/23/2024. Further review revealed there was no pain reassessment within 1 hour of receiving a PO pain medication or prior to disposition as per policy.

In an interview on 05/15/2024 at 9:20 a.m. S1DED confirmed the above mentioned findings.

Based on record review and interview, the hospital failed to be in compliance with 42 CFR §489.20 (l) of the provider's agreement which requires hospitals comply with 42 CFR §489.24, Special responsibilities of Medicare hospitals in emergency cases as evidenced by the hospital failing to ensure a medical screening examination was provided to each patient presenting to the ED to determine whether or not an emergency medical condition existed. This deficient practice is evidenced by failing to provide an appropriate medical screening exam with a complete psychiatric evaluation for 1 (#12) of 1 (#12) patients who presented to the emergency department with suicidal ideation. (see findings tag A-2406).

Based on record reviews and interviews, the hospital failed to ensure all patients who presented to emergency department (ED) had an appropriate medical screening exam. This deficient practice is evidenced by failing to provide an appropriate medical screening exam with a complete psychiatric evaluation for 1 (#12) of 1 (#12) patients who presented to the emergency department with suicidal ideation.
Findings:

Review of Policy titled Medical Staff Obligations for Emergency Services, dated 05/21/2019, revealed in part: All individuals who present to emergency requesting a medical examination or treatment shall receive care outlined by EMTALA and other appropriate regulations and standards for patient care.

A review of Patient #12's medical record revealed the 6 year old female presented to the ED on 04/24/2024 at 4:09 p.m. Patient #12 was triaged at 4:27 p.m. as a level 2 Emergent for a swallowing staples in an attempt to harm self. RN performed Suicide Risk Assessment at 4:36 p.m. which patient scored as high risk for suicide and this was only suicide risk assessment done during the 04/24/2024 visit. Patient #12 was seen by S7MD at 4:58 p.m. and an x-ray was ordered for swallowing staples at school to harm self. S7MD consulted the social worker and the consult was completed on 04/24/2024 at 5:02 p.m. On 04/24/2024 at 6:52 p.m. the ED MD ordered Patient #12 to be discharged home with mother to follow up with mental health appointment on 04/25/24 at 11:00 a.m. At 7:09 p.m. Patient #12 stated to the nurse "then can I have another staple to put in my mouth". It was documented that nurse notified ED MD and ED MD was at Patient #12's bedside, but no further documentation was noted related to Patient #12's comments. Patient #12 was discharged at 7:13 p.m. on 04/24/24. Patient #12 had an appointment with her mental health provider on 04/25/2024 at 11:00 a.m. The Physician's Emergency Certificate (PEC) exam date and time was 04/25/2024 at 11:00 a.m. The PEC was signed at 11:53 a.m. on 04/25/2024 by the mental health provider documenting that Patient #12 was a danger to self and others. Patient #12 returned to the ED on 04/25/2024 at 12:30 p.m. on a Physician's Emergency Certificate (PEC) after seeing mental health provider. Patient #12 was transferred on 04/25/2024 at 6:33 p.m. to another facility on a PEC for psychiatric care.

On 05/15/2024 at 11:30 a.m. S1DED verified that Patient #12 did not have a psychiatric evaluation while in the ED on 04/24/2024 and returned to the ED on 04/25/2024 on a PEC. S1DED also verified the ED physicians at the facility routinely perform their own psychiatric examination and will place patients under a PEC if they feel it is required for the safety of the patient.