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Based on interview, observation and document review, the hospital failed to maintain compliance with the Condition of Participation: Emergency Services resulting in a situation posing immediate jeopardy to patients. The legal responsibility to assure the hospital meets all aspects of Medicare's Conditions of Participation is with the Governing Body.

Findings include:

The Governing Body must ensure that the medical staff is accountable for the quality of care provided to patients. The governing body is responsible for the conduct of the hospital and this conduct includes the quality of care. On January 5, 2015, Patient #1 came to the emergency department for treatment of a possible miscarriage. The patient was not triaged according to the hospital policy and procedure classifying the patient at a less severity than what was required.

The internal investigation related to the 1/5/15 patient experience determined that the emergency department was over-saturated with high acuity patients and did not request assistance from other departments in the hospital. The facility has an in-house OB physician available and the physician was not called for several hours after the patient admitted to the emergency department. The plan to secure additional resources in the event the ED was overwhelmed with patients or acuity of patients was discussed at the 1/20/15 internal investigation meeting. At the time of this investigation, no plan or policy revision was found.

The hospital failed to assure its' policies and procedures governing medical care were established, evaluated and updated by the medical director. Failure to have ongoing/continued assessment of the medical care policies and procedures for patients places patients at risk of receiving less than standard of care based on current practices.

The emergency department must have a designated triage nurse that has training and identified competencies to perform this function. The emergency department job description for the emergency registered nurse does not include minimum competency requirements for the triage nurse assignment. The annual competency/skills assessment for the ED RN does not include assessing this skill.

Based on the above deficiencies, CMS determined that a condition existed at the respondent facility that posed an immediate and serious threat to patient safety. The facility was notified of the Immediate Jeopardy and implemented immediate corrective measures that abated the Immediate Jeopardy prior to the investigator leaving the on-site investigation. The Conditions continue to be out of compliance until a formal plan of correction can be established and implemented.

Based on interview, observation and document review, the respondent facility failed to properly assess and assign an appropriate level of care to an emergency patient based on the Emergency Severity Index (ESI), the triage tool for emergency department care utilized by the respondent facility. Failure to properly assess (triage) a patient's appropriate level of care may have caused a delay in the medical assessment and initiation of care for a patient and patients that enter the emergency debarment at the respondent facility.

Findings include:
Patient #1 received emergency care on 1/4/15 and 1/5/15. On 1/4/15, the patient requested emergency department care related to a fall resulting in a left foot injury. During the 1/4/15 emergency department assessment, the patient stated she was experiencing nausea and abdominal pain the "last few weeks". The patient was tested for pregnancy and according to the medical record documentation, the patient was determined to be approximately 16 weeks pregnant via ultrasound. The emergency department found a fetal heart rate at approximate 150 beats per minute.

The patient entered the emergency department via ambulance on 1/5/15 at 1756 with the complaint that a "baby's foot" was seen while the patient was using the bathroom. According to the ESI (Emergency Severity Index) tool used by the facility, "all pregnant patients with localized abdominal pain, vaginal bleeding or discharge, 14 to 20 weeks and over should be assigned ESI level 2 and seen by a physician rapidly". ESI Level 2 patients are to be seen prior to ESI Level 3, 4, and 5 patients by the physician/provider. Patient #1 was assigned an ESI level 3 during triage at 1758 and not physically assessed by a registered nurse or physician until 2201 pm to determine if a fetal foot was in the vaginal tract as indicated by the patient.

The respondent facility failed to identify triage competency skills for the registered nurses performing the triage functions. Based on interview with RN #2, a registered nurse must be working in the emergency department for at least one year prior to performing the triage process. No other competencies were identified as necessary/required to perform the triage process for patients. RN #3 performed the triage on the referenced patient and did not meet the one year experience criteria.

Based on the above information, an Immediate Jeopardy was identified. The facility was notified of the finding and implemented an immediate remediation plan prior to the investigator exiting the facility. The respondent facility stated they would adopt the parent corporation's (CHI Franciscan Health System) algorithm: Care of Obstetrical and Postpartum Patients Presenting to a Franciscan Emergency Department. The algorithm was put in place during the investigation on 7/13/15. Starting immediately (1315 pm on 7/13/15), the registered nurses assigned to complete the triage process on patients "will have completed the triage RN competency test". The Obstetric ESI level was posted in the triage area for immediate referral by the registered nurses. The Nursing Director of Emergency Services, the Nursing Manager of Emergency Services and the ED Medical Director will monitor the immediate plan until a permanent correction is implemented.

The Condition of Participation remains deficient as identified through the following standards.

Based on interview and document review, the hospital failed to integrate the emergency department services with other departments in the hospital. Failure to utilize other services of the hospital to the full extent of its patient care resources to assess and render appropriate care to an emergency patient places patient's at risk of a delay in treatment and/or potential harm.

Findings include:
Patient #1 entered the facility on 1/5/15 with a obstetric complaint. The respondent facility maintains an "in-house" obstetric (OB) physician. According to the medical record, the OB physician was not notified for approximately three hours after the patient's arrival. The OB physician was the first physician to perform a vaginal exam on the patient at 2251 pm. This was validated by the ED medical director and ED nursing director.

Based on interview and document review, the respondent facility failed to assure its' policies and procedures governing medical care are established, evaluated and updated by the medical director. Failure to have ongoing/continued assessment of the medical care policies and procedures for patients places patients at risk of receiving less than the standard of care based on current practices.

Findings include:
The policies and procedures did not have documentation that the medical director reviewed, evaluated and/or updated the policies governing medical care provided in the emergency department. The current medical director stated s/he was not aware of the requirement. The Regional Director of Risk Management stated the practice of involving medical directors in policy review was to be implemented by the end of the month. On review of the medical director's contract with the hospital, the requirement to participate in policy development and review was not found. This was validated by the facility's Regional Risk Manager.

Based on interview, document review and observation, the hospital failed to provide adequate personnel qualified in all aspects of emergency care to meet the needs of the patients. Failure to provide an adequate number of personnel with documented competency skills places patients at risk for receiving less than standard of care medical treatment and/or a delay in treatment.

Finding include:
The emergency department's internal investigation documented that there were two medical emergency codes ongoing in the department on 1/5/15 starting at 1730 pm, (Code Blue/Code Trauma). The code situation occupied most of the emergency department resources during the hours of 1730 pm to 2130 pm. The hospital does not have a written procedure to access additional resources in the event of an increase in patient census or patient acuity. On interview with MD#2 on 7/13/15 at 1030, s/he stated that the need for additional help is "subjective" and there are no written protocols for requesting additional resources for the physicians. This was confirmed by the medical director and ED Nursing Director. During the internal case review for Patient #1's care on 1/20/15, the reviewers concluded that additional help was needed even though the department was staffed at the core staffing levels and a plan of correction could be to contact help in other departments and/or enlist the nursing supervisor to assist. There is no evidence that the plan was implemented or a protocol/policy/procedure was developed.

The emergency department job description for the emergency registered nurse does not include minimum competency requirements for the triage nurse assignment. The annual competency/skills assessment for the ED RN does not include assessing this skill. On interview with RN #4 on 1/13/15 at 0920, s/he stated that a nurse had to have at least one year of ED experience. This was not confirmed in any document. On interview with RN #2 on 7/13/15 at 0930 am, s/he stated that the RN, after one year of experience, was required to 'shadow' an experienced triage nurse but RN#2 could not state what time frame the 'shadowing' was expected and could not recall his/her own experience. The 'shadowing' requirement was not found in any document. RN #1 triaged Patient #1 and did not have one year of emergency nursing experience.


On interview with the ED Nursing Director, s/he stated that there was a triage course offered approximately two years ago but no current training/skills assessment had been offered/assessed since that time. This was confirmed in five out of five registered nurse personnel file reviewed by this investigator.