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Based on a review of clinical records, review of facility documentation, policies, and staff interviews, for two of five patients (Patients #48 and #49) who filed complaints, the hospital failed to provide written notice to the patient and/or patient's representative regarding the determination of the grievance. The findings include:

a. Patient #48 initiated a complaint on the Patient Relations telephone line on 6/24/11 regarding treatment that he/she received in Same Day Surgery on 6/23/11 by a staff member. Although the Director of Perioperative Services called the patient to follow up regarding his/her concerns, hospital documentation failed to reflect a letter regarding a resolution to his/her concerns.

b. Patient #49 was seen in the emergency Department on 7/21/11 for complaints of jaw pain. The patient initiated a complaint on 7/27/11 to the Director of the Emergency Department as he/she was not satisfied with the management of his/her complaints. A review of hospital documentation identified that the Director of the Emergency spoke with the patient regarding the care and services he/she received in the Emergency Department, however hospital documentation failed to reflect a letter regarding a resolution to his/her concerns.

A review of the Patient Relations Policy identified that the Vice President of Medical Affairs shall issue a written response to the patient and or family member within 30 working days of the receipt of the complaint. Interview and review of facility documentation with the Vice President of Medical Affairs on 10/24/11 at 12:55 PM identified that follow up communication for Patients #48 and 49 complaints had not been completed according to hospital policy.

Based on review of clinical records, review of policies, procedures, hospital documentation, and staff interviews, the facility failed to ensure that the quality program addressed patient safety for patients at high risk for suicidality and/or falls.
Refer to A 285 and A 1104.

Based on interviews and review of hospital documentation, the facility failed to develop quality performance improvement activities regarding high risk safety assessments in the Emergency Department. The findings include:

A review of the Quality Improvement meeting minutes and Emergency Staff meeting minutes for 2011 identified ongoing monitoring of constant observation documentation and/or goals to reduce falls, however failed to include monitoring of patients who were at risk for falls and/or who presented to the Emergency Department with behavioral health concerns. Review of the Department of Nursing staff competency plan identified that staff meetings are a forum of addressing quality improvement issues on the unit and all staff are expected to participate in the CQI (continuous quality improvement ) process. Review of the Department of Emergency Scope of Care identified that the Medical Director of Emergency and Critical Care Services assumes responsibility to assure that the quality, safety, and appropriateness of emergency patient care are monitored and evaluated and that appropriate actions based on findings taken. Interview with the Director of Emergency Medicine on 10/21/11 at 10:10 AM and The Nurse Manager of the Emergency Department on 10/21/11 at 1:11 PM failed to provide evidence of quality improvement initiatives related to behavioral health in the Emergency Department. Interview with the Vice President of Patient Care Services and the Regulatory Liaison on 10/20/11 at 2:00 PM failed to provide evidence of tracking and/or monitoring of appropriateness of the Fall Risk Assessment and/or suicide assessment in the Emergency Department.

Cross reference A1104.

Based on review of clinical records, review of facility policy/procedure and interviews, for seven (7) of forty-three (43) patients (Patients # 1, 29, 32, 35, 54, 55, and 62) that were provided care and services, the hospital failed to ensure that the clinical records were complete and/or accurate. The findings include:

a. Patient #1 was arrived at the Emergency Department (ED) on 7/2/11 at 10:48 A.M. with the complaint of left arm injury after a fall at home. Review of the medical orders, diagnostic imaging reports, clinical notes, physician procedure notes, informed consent and discharge instructions identified that the medical provider, PA #1, was a physician. Interview with the Medical Director of the ED and the Information Technology Director, on 10/13/11 at 1:05 P.M., identified that PA #1 is not a physician and the electronic ED record erroneously identified him/her as a physician.

In addition, review of the clinical record identified an informed consent form, dated 7/2/11, for a hematoma block and a closed reduction of wrist fracture unsigned by a medical provider. Interview with PA #1, on 10/13/11 at 1:22 P.M., identified that he/she explained the procedures to Patient #1 and then performed the procedures however, failed to sign the form. Review of the policy and procedure, titled Informed Consent, identified that the responsible physician must obtain informed consent and witness that he/she explained the procedure to the patient.

b. Patient #29 arrived at the ED on 10/19/11 at 1:48 P.M. with the complaint of leg numbness and alcohol abuse. Review of the medical orders and clinical notes identified that the medical provider, PA #2, was a physician.

c. Patient #32 was arrived at the ED on 10/14/11 at 1:09 P.M. with the complaint of suicidal ideation's. Review of the medical orders, clinical notes and discharge instructions identified that the medical provider, PA #3, was a physician.

d. Patient #35 was arrived at the ED on 10/16/11 at 11:34 A.M. with the concern of confrontation with siblings, depression and threat to harm him/herself. Review of the medical orders, clinical notes and discharge instructions identified that the medical provider, PA #3, was a physician.

e. Patient #54 was arrived at the ED on 10/22/11 at 11:45 A.M. with the compliant of abdominal pain. Review of the medical orders, clinical notes and notification note identified that the medical provider, PA #4, was a physician.

f. Patient #55 was arrived at the ED on 10/22/11 at 3:21 P.M. with the compliant of depression. Review of the medical orders, clinical notes and discharge instructions identified that the medical providers, PA #4 and PA #2, were physicians.

g. Patient #62 was arrived at the ED on 10/23/11 at 3:42 P.M. with the compliant of suicidal ideation's. Review of the medical orders, clinical notes and discharge instructions identified that the medical provider, PA #2, was a physician.

Based on interviews, review of Medical Staff Bylaws, and facility documentation, the hospital failed to implement the suspension of one physician who had delinquent discharge summaries in accordance with the hospital bylaws. The findings include:

A review of the delinquent records report dated 10/17/11 identified that MD #2 was suspended as a result of delinquent discharge summaries. A review of the operating room schedule for 10/20/11 identified that MD #2 was scheduled to perform surgery on patient #44, 45 and 46.

Interview with the Department Chairman of Surgery and the Vice President of Medical Affairs on 10/21/11 at 12:00 PM identified that the medical staff is made aware of delinquent records via email and that the staff member will not be allowed to perform surgery while suspended.

Interview with the Nurse Manager of Perioperative Services on 10/25/11 at 9:06 AM identified that the Operating Room receives a daily list of suspended practitioners and prior to scheduled surgery; the provider is directed to complete records to maintain compliance according to the hospital bylaws. He/She further identified that although there is a system in place to ensure that the provider is compliant, MD #2 was not directed by the Operating room staff to complete his/her medical records prior to surgery on 10/20/11.

Interview with the Vice President of Medical Affairs on 10/24/11 at 12:45 PM identified that he/she was not aware that MD#2 performed surgery while suspended until it was brought to his/her attention by the surveyor.

Further review of the clinical record of Patient #44 identified that MD #2 provided post operative care to the patient on 10/21/11, 10/22/11 and 10/23/11 while suspended. Additionally, MD#2 provided follow up care to Patient #54 who had emergency surgery on 10/22/11.

According to the Medical Staff Bylaws, once a physician is placed on medical record suspension, he/she is not allowed to admit new patients, perform new consults, perform surgeries, or performs procedures except on patients already in his/her care.

A review of Hospital documentation dated 10/17/11 at 2:32 PM identified that a facsimile was sent to MD#2's office indicating the outstanding medical record and implications of his/her practice if not completed in a timely manner. Interview with MD #2 on 10/24/11 at 1:28 PM identified that he/she was not aware of the medical record suspension.

Subsequent to surveyor inquiry, the Vice President of Medical Affairs issued an immediate corrective action plan to all medical staff that included rescheduling surgery to the end of the day for those providers who are suspended, allowing them time to complete their delinquent medical records.

Based on a review of clinical records, review of policies, procedures, hospital documentation, and interviews, the hospital failed to ensure that emergency department policies were implemented and/or comprehensive to meet the needs of twenty-two (22) of forty-three (43) patients at risk for suicide and/or falls and/or provided physician referrals upon discharge for three (3) patients. The findings include:

Refer to A 1104.

Based on a review of clinical records, review of policies, procedures, hospital documentation, and interviews, the hospital failed to ensure that emergency department policies were implemented and/or comprehensive to meet the needs of twenty-two (22) of forty-three (43) patients at risk for suicide and/or falls (1, 12, 7, 27, 29, 30, 31, 32, 33, 34, 35, 37, 38, 39, 40, 41, 43, 56, 57, 60, 63, and 64) and/or for three (3) patients reviewed for discharge planning (59, 63, and 26), the hospital failed to provide physician referrals upon discharge. The findings include:

a. Patient #1 arrived at the Emergency Department (ED) on 7/2/11 at 10:48 A.M. with the complaint of left arm injury after a fall at home. Review of the nursing triage note, dated 7/2/11 at 11:07 A.M., identified that the Patient #1 routinely took nine medications daily and was not determined to be at risk for falls. Interview with RN #2, on 10/13/11 at 11:03 A.M., identified that although Patient #1 fell at home and took multiple medications, he/she identified that the patient was not at risk to fall.

At approximately 12:45 P.M., Patient #1 was found lying on the floor and had sustained a nasal fracture. The hospital failed to ensure the patient was accurately assessed as a fall risk.

Review of the Ruby Slipper Fall Prevention program directed that all patients will be assessed using the fall risk tool in EMPOWER with the ruby slipper prevention plan implemented for high risk patients. Review of the Empower fall risk program identfied patient's are at risk for falls if a recent history of falls was noted, had altered mobility, and/or consumed multiple medications (polypharmacy).

Interviews with the Nursing Director, on 10/21/11 at 12:02 P.M. and on 10/25/11 at 10:10 A.M., identified that at triage, the nurse assess each patient for risk of falls based on history of falls, multiple medications and altered mobility and there are no definitions for those three parameters provided by the hospital.


b. Patient #12 arrived at the ED on 9/22/11 at 12:43 A.M. via ambulance with the complaint of chest pain for one week and anxiety. Review of the nursing notes, dated 9/22/11 at 1:45 A.M., identified that Patient #12 informed RN #8 that he/she was suicidal, had a plan and would not inform the nurse of the plan. The clinical record failed to reflect that a suicide risk assessment was conducted. The documentation reflected that MD #1 was informed of the patient's statement. The patient was transported to Diagnostic Imaging at 1:50 A.M. without the benefit of a comprehensive assessment as directed by hospital policy. At 3:30 A.M., a constant attendant was assigned to monitor Patient #12, one hour and forty-five minutes after he/she voiced suicidality. The hospital failed to provide hospital attire, inventory the patient's belongings, and secure the belongings as directed by the policy.

The record failed to reflect that the physician, MD #1, examined and/or evaluated the patient regarding his/her suicidal statements until 5:10 A.M. (three hours and twenty-five minutes later). Interview with MD #1, on 10/21/11 at 9:50 A.M., identified that the patient was being monitored by the staff and a crisis evaluation was ordered.

Review of the policy for Suicidal or Impaired Patients in the ED identified that the patient who has expressed intent to commit suicide will have a medical screening examination that will determine whether the patient is medically stable for a crisis evaluation.

Review of Suicide Risk Assessment policy identified that for any patient who presents with an emotional/behavioral disorder, the nurse must complete a suicide risk assessment which includes if the patient is depressed, if he/she has thoughts to harm self and/or others, feelings of helplessness and/or hopelessness, if he/she has plan to harm self and/or others, if he/she has means to implement the plan and if he/she has access to firearms. The policy directs that any ED patient who presents with suicidal risk is changed into hospital attire, his/her personal belongings are inventoried and secured away from the patient area and the patient is placed under constant observation.

The Emergency Department policy, titled Nursing Standards of Care, identified that patient safety will be assessed on all patients with appropriate interventions as needed.

In addition, although the record reflected that the patient routinely took eight medications daily, a fall risk assessment was not completed in accordance with hospital policy.

c. Patient #7 arrived at the ED on 10/11/11 at 7:00 P.M. via ambulance in police custody with the compliant of fall at home and alcohol ingestion. Review of the nursing triage note, dated 10/11/11 at 7:01 P.M., identified that the patient was uncooperative with answering questions and was determined to not be at risk for falls. Review of the clinical record failed to reflect that a comprehensive nursing assessment for suicide risk was conducted in accordance with facility policy.

During a tour of the ED, on 10/12/11 from 9:10 A.M. to 10:15 A.M., Constant Attendant (CA) #1 was observed to be assigned to monitor Patient #7. Review of the instructions for monitoring this patient identified that the patient was at risk for falls, a discrepancy from the triage nursing assessment. Interview with the Nursing Director, on 10/12/11 identified that at triage, the nurse would assess for risk for falls based on history of falls, multiple medications, altered mobility and/or altered mentation.

d. Patient #27 was seen in the ED on 9/21/11 at 10:45 P.M. with suicidal ideation's that included a plan to overdose. The clinical record failed to reflect that a suicide risk assessment was conducted in accordance with facility policy. Physician orders dated 9/21/11 at 11:22 P.M. directed to provide a constant attendant. Interview and review of the clinical record with the Vice President of Patient Care Services, on 10/13/11 at 2:25 P.M., failed to provide evidence that the constant observer was implemented until 12:10 A.M., approximately forty (40) minutes later. The patient was evaluated by the Crisis Worker and Psychiatrist and was discharged home on 9/22/11 at 11:37A.M.

e. Patient #29 arrived at the ED on 10/19/11 at 1:48 P.M. with the complaint of leg numbness and alcohol abuse. The clinical record failed to reflect that a suicide risk assessment was conducted in accordance with facility policy. Review of the clinical record identified that a constant attendant was assigned to the patient on 10/19/11 at 10:00 P.M., eight (8) hours and twelve (12) minutes following triage.
Review of the constant attendant documentation, dated 10/20/11 at 6:00 A.M., identified that the constant attendant was removed from observing/monitoring Patient #29. The record failed to reflect that an assessment for the discontinuation of monitoring was documented. At 7:00 A.M. the constant attendant was reinstated, absent of a documented assessment.

f. Patient #30 arrived at the ED on 10/19/11 at 2:53 P.M. with the complaint of abdominal pain and alcohol ingestion. Review of the nursing triage note, dated 10/19/11 at 2:56 P.M., identified that the patient smelled of alcohol. Review of the clinical record failed to reflect that a comprehensive nursing assessment for suicide risk was conducted in accordance with facility policy.
At 10:00 P.M. a constant attendant was initiated for Patient #30, seven (7) hours and seven (7) minutes following triage. Review of the constant attendant documentation, dated 10/20/11 at 6:00 A.M., identified that the constant attendant was removed from observing/monitoring Patient #30. The record failed to reflect that an assessment for the discontinuation of monitoring was documented. At 7:00 A.M. the constant attendant was reinstated, absent of a documented assessment.

Interview with the Nursing Director, on 10/21/11 at 12:02 P.M., identified that review of the clinical records failed to reflect that the nurses involved reassessed these patients with changes in the level of constant observation.
The Constant Attendant Guidelines identified that the nurse assesses the need for an increased level of observation of the patient based on patient needs and the staff ability to meet the patient's safety needs.

g. Observations during a tour of the Emergency Department on 10/20/11 at 12:45 P.M. identified that a Constant Observer was assigned to monitor Patient #29 and #30. The Constant Observer was observed to leave his/her post, which was directly across from the patients rooms, and walked down the hallway, out of the line of vision, to obtain ice for one of the patients. Interview with the Nursing Director of the Emergency Department, on 10/20/11 at 1:00 P.M., identified that when a staff member is assigned to constant observation duties, he/she may not leave the area until relieved by another staff member.

Review of the policy and procedure, titled Constant Attendant Guidelines, identified that the constant attendant must be able to visualize the patient's head and neck at all times.

h. Patient #31 arrived at the ED on 10/20/11 at 1:03 P.M. with the complaint of suicidal ideation's. Review of the nursing triage note, dated 10/20/11 at 1:28 P.M., identified that Patient #31 routinely took six (6) medications daily. The hospital failed to conduct a fall risk assessment in accordance with facility policy.

i. Patient #32 arrived at the ED on 10/14/11 at 1:09 P.M. with the complaint of suicidal ideation's. Review of the nursing triage note, dated 10/14/11 at 1:12 P.M. failed to reflect that a comprehensive nursing assessment for suicide risk was conducted in accordance with facility policy. The record reflected a thirteen (13) minute delay before the patient was assigned a constant attendant and a one hour and forty-three (43) minute delay in removing the patient's belongings and/or by changing the patient into hospital attire in accordance with policy.

j. Patient #33 arrived at the ED on 10/15/11 at 12:34 P.M. with the complaint of depression. Review of the nursing triage note, dated 10/15/11 at 12:49 P.M., identified that the Patient #33 routinely took four (4) medications daily and two medications as needed. The clinical record failed to reflect that a fall risk assessment was completed.

k. Patient #34 arrived at the ED on 10/14/11 at 6:37 P.M. via ambulance after a hanging with cardiopulmonary resuscitation was performed successfully. Review of the nursing triage note, dated 10/14/11 at 6:37 P.M., failed to reflect that a suicide risk assessment was conducted in accordance with facility policy. Although the record identified that two correction officers were present, the hospital failed to implement their policy which included in part, constant observation by the hospital staff. Interview with RN #9, on 10/25/11 at 10:26 A.M., identified that he/she did not provide a constant attendant for Patient #34.

l. Patient #35 arrived at the ED on 10/16/11 at 11:34 A.M. with a threat to harm him/herself. Review of the nursing triage note, dated 10/16/11 at 11:34 A.M., failed to reflect that a suicide risk assessment was conducted in accordance with facility policy. Review of the clinical record identified that there was an eleven (11) minute delay before the hospital provided constant observation for this patient.

m. Patient #37 arrived at the ED on 10/19/11 at 1:13 P.M. via ambulance in police custody with the compliant of suicidal ideation and alcohol ingestion. Review of the nursing triage note, dated 10/19/11 at 1:16 P.M., failed to reflect that a comprehensive nursing assessment for suicide risk was conducted in accordance with facility policy.

n. Patient #38 arrived at the ED on 10/15/11 at 8:10 P.M. with the compliant of drug overdose. Review of the nursing triage note, dated 10/15/11 at 8:17 P.M., failed to reflect that a suicide risk assessment was conducted in accordance with facility policy. Review of the clinical record identified that there was a delay of forty-three (43) minutes before the hospital provided constant observation for this patient.

o. Patient #39 arrived at the ED on 4/24/11 at 10:46 P.M. via ambulance in police custody with the complaint of suicidal ideation. Review of the nursing triage note, dated 4/24/11 at 11:48 P.M., failed to reflect that a suicide risk assessment was conducted in accordance with facility policy. Review of the clinical record identified that there was a delay of forty-four (44) minutes before the hospital provided constant observation for this patient.

p. Patient #40 arrived at the ED accompanied by a family member on 3/12/11 at 10:04 A.M. with the complaint of suicidal ideation's. Review of the clinical record identified that the patient was triaged at 11:15 A.M., one hour and eleven minutes after arrival, and was assigned the triage level of 2 (urgent). Interview with the Nurse Director of the ED, on 10/21/11 at 12:02 P.M., identified that he/she could not explain the reason for delay for triage of this patient. Review of Triage Policy and Procedures identified that a level 2 required urgent evaluation with the goal that every patient is triaged by a Registered Nurse in less than five minutes.
Once triaged, the note failed to reflect that a suicide risk assessment was completed in accordance with facility policy. Review of the clinical record identified that there was a delay of twenty-eight (28) minutes before the hospital provided constant observation for this patient.

q. Patient #41 arrived at the ED on 4/14/11 at 2:49 P.M. via ambulance in police custody with the compliant of hallucinations. Review of the nursing triage note, dated 4/14/11 at 3:09 P.M., identified that the patient was confused, could not follow directions and had a history of substance abuse. The nursing triage note failed to reflect that a suicide risk assessment was conducted in accordance with facility policy.

r. Patient #43 was seen in the ED on 10/2/11 at 3:47A.M. subsequent to an overdose of medication. A review of the clinical record identified that the patient was positive for suicidal ideation's and alcohol consumption. Review of the clinical record failed to reflect that a suicide risk assessment was conducted in accordance with facility policy. Interview and review of the clinical record with the Director of the Emergency Department on 10/21/11 at 1:15 PM failed to provide evidence that a constant observer was assigned to the patient.

A review of the Fall Risk Assessment for Patient #43 identified that the patient was not at risk for falls. A review of the clinical record identified the patient was prescribed multiple medications and was at risk for impaired mobility as a result of alcohol intoxication and the consumption of an unknown quantity of Trazadone (antidepressant), rendering the fall risk assessment inaccurate.

s. Patient #56 was seen in the ED on 10/21/11 at 9:02 P.M. for racing thoughts and suicidal ideation's. A review of the clinical record identified that the patient's past medical history included multiple medications. The clinical record failed to reflect that a fall risk assessment was conducted in accordance with facility policy. The record identified that the patient was provided with hospital attire at 10:00 P.M., approximately one hour later.

t. Patient #57 arrived at the ED on 10/23/11 at 11:22 A.M. with the need/request for alcohol detoxification. Review of the nursing triage note, dated 10/23/11 at 11:26 A.M., identified that Patient #57 routinely took seven medications daily and two medications as needed. The clinical record failed to reflect that a fall risk assessment was conducted in accordance with facility policy.

u. Patient #60 was seen in the ED on 10/21/11 at 6:56 P.M. with complaints of weakness, having almost passed out at dinner. A review of the clinical record identified that the patient was prescribed multiple medications at home. The clinical record failed to reflect that a fall risk assessment was conducted in accordance with facility policy.

v. Patient #63 arrived at the ED on 10/23/11 at 7:18 P.M. via ambulance in police custody with the compliant of suicidal behavior. Review of the nursing triage note, dated 10/23/11 at 7:28 P.M., identified that the Patient #63 routinely took eight medications daily. The clinical record failed to reflect that a fall risk assessment was conducted in accordance with facility policy.

w. Patient #64 arrived at the ED on 10/21/11 at 6:00 A.M. via ambulance with police custody with the need/request for medication adjustment to calm him/her down. Review of the nursing triage note, dated 10/21/11 at 6:13 A.M., failed to reflect that a suicide risk assessment was conducted in accordance with facility policy.
Review of clinical records and interviews with the Nurse Director of the ED, on 10/21/11 at 12:02 P.M., identified that the nursing assessments for suicidal risk for the identified patients was not either complete and/or comprehensive.

x. Patient #59 arrived at the ED on 10/23/11 at 4:36 P.M. with the need/request of alcohol and drug detoxification. Review of the nursing triage note, dated 10/23/11 at 4:43 P.M., identified that Patient #59 had no primary care physician. Review of the discharge instructions, dated 10/23/11 at 9:11 P.M., directed that Patient # 59 follow-up with his/her primary care physician in two days although it was identified that he/she had no primary care physician.

y. Patient #63 arrived at the ED on 10/23/11 at 7:18 P.M. via ambulance in police custody with the compliant of suicidal behavior. Review of the nursing triage note, dated 10/23/11 at 7:28 P.M., identified that the Patient #63 had no primary care physician. Review of the discharge instructions, dated 10/24/11 at 9:14 A.M., directed that Patient # 63 follow-up with his/her primary care physician in two days although it was identified that he/she had no primary care physician.

z. Patient #26 was seen in the Emergency Department on 9/29/11 at 1:33 AM. The patient informed a sibling that "he/she wanted to cause self harm" and was brought to the Emergency Department following police intervention. Although the patient made a suicidal statement to police, once hospitalized, he/she denied intention to kill self, and insisted on being discharged from the hospital. A review of the Emergency Department record lacked documentation of a primary physician for follow up care upon discharge from the hospital.

Interview with the Nurse Director of the ED, on 10/25/11 at 10:10 A.M., identified that he/she could not explain why the physician referrals for these patients did not occur.

Review of the Scope of Care policy identified that the Emergency Department assures that appropriate follow-up care for all discharged patients in accordance with established policies.

The Discharge Instructions policy identified that at all discharge instructions are communicated verbally and in writing, at discharge if the patient does not have a primary care physician, the patient/is asked if he/she has a preference and if no preference is identified the patient is referred to one of the on-call physicians.

The policy, titled Emergency Department Nursing Standards of Care, identified that at discharge the written instructions include referral to a primary medical doctor.