HospitalInspections.org

Based on observation, policy review, staffing plan review, staffing report review, patient volumes review, medical record review ,EMS (Emergency Medical Services) Patient Care reports and staff interview, EMS, physician and staff interviews the hospital's governing body failed to provide oversight and have systems in place to ensure the protection and promotion of patient's rights to ensure a safe environment for emergency department patients; failed to maintain an organized and effective quality assessment and improvement program; failed to have an organized nursing service to meet patient care and safety needs and failed to meet the emergency needs of patients.

The findings include:

1. Based on observation, policy review, staffing plan review, staffing report review, patient volumes review, medical record review, and staff interview, the facility failed to provide a safe environment for patients presenting to the emergency department (ED) for 10 of 20 sampled ED patients. ( Patient #7, #20, #4, #8, #6, #31, #32, # 28,# 29,# 30). ED nursing staff failed to assess, monitor and evaluate patients to identify and respond to changes in patient conditions. The facility staff failed to ensure qualified staff were available to provide care and treatment for patients who arrived in the ED. The cumulative effects of these practices resulted in an unsafe environment for ED patients.

~cross refer to 482.13 Patient Rights' Standard: Tag A 0144

2. Based on facility policy review, medical record review, and staff interview, the facility staff failed to identify the use of chemical restraints in 2 of 2 chemically restrained patient records sampled (Patient #8, 23).

~cross refer to 482.13 Patient Rights' Standard: Tag A 0160

3. Based on policy review, medical record review, and staff interview, the facility staff failed to document a physician's order for restrictive interventions in 1 of 2 violent restraint records reviewed (Patient #8).

~cross refer to 482.13 Patient Rights' Standard: Tag 0169

4. Based on review of the facility's Quality Assurance and Performance Improvement Program plan, process improvement documents, EMS turn around time data, medical record reviews, observations, and staff interviews, the facility staff failed to collect accurate turn-around-time data and implement performance improvement measures to decrease EMS turn-around-times within the Emergency Department.

~cross refer to 482.21 Standard: QAPI Quality Improvement Activities, Tag A 0283

5. Based on policy and procedure review, closed medical record reviews, and staff interviews, the nursing staff failed to assess, monitor and evaluate patients who presented to the emergency department (ED) for 3 of 20 sampled ED patients (Patient #7, #20, #4). Patients #7 and #20 had a change in condition that was not assessed by nursing staff and the patient's conditions deteriorated. Patient #7 subsequently died.

~cross refer to 482.23 Nursing Standard: Tag A 0395

6. . Based on hospital policy review, EMS (Emergency Medical Services) Patient Care Reports, EMS staff and physician interviews, the hospital failed to ensure an organized and effective emergency services by failing to ensure emergency services staff provided an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 5 of 20 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patients #31, #32, #28, #29, #30 ).

~Cross refer to 482.55 : Emergency Services Standard Tag A 1101

7. Based on observation, policy review, staffing plan review, staffing report review, patient volumes review, medical record review, and staff interview, the facility failed to maintain adequate numbers of qualified personnel available to meet the needs of incoming patients with emergent conditions in 9 of 10 patients who arrived by EMS (Patient #8, #20,# 24,# 6 #31, #32, # 28,# 29,# 30).

~Cross refer to 482.55 : Emergency Services Standard Tag A 1112

Based on observation, policy and procedure review, staffing plan review, staffing report review, patient volumes review, medical record review, and staff and physician interviews, the hospital failed to promote and protect a patient's rights by failing to provide a safe environment to Emergency Department patients.

The findings included:

1. Based on observation, policy review, staffing plan review, staffing report review, patient volumes review, medical record review, and staff interview, the facility failed to provide a safe environment for patients presenting to the emergency department (ED) for 10 of 20 sampled ED patients. ( Patient #7, #20, #4, #8, #6, #31, #32, # 28,# 29,# 30). ED nursing staff failed to assess, monitor and evaluate patients to identify and respond to changes in patient conditions. The facility staff failed to ensure qualified staff were available to provide care and treatment for patients who arrived in the ED. The cumulative effects of these practices resulted in an unsafe environment for ED patients.

~cross refer to 482.13 Patient Rights' Standard: Tag A 0144

2. Based on facility policy review, medical record review, and staff interview, the facility staff failed to identify the use of chemical restraints in 2 of 2 chemically restrained patient records sampled (Patient #8, 23).

~cross refer to 482.13 Patient Rights' Standard: Tag A 0160

3. Based on policy review, medical record review, and staff interview, the facility staff failed to document a physician's order for restrictive interventions in 1 of 2 violent restraint records reviewed (Patient #8).

~cross refer to 482.13 Patient Rights' Standard: Tag 0169

Based on observation, policy review, staffing plan review, staffing report review, patient volumes review, medical record review, and staff interview, the facility failed to provide a safe environment for patients presenting to the emergency department (ED) for 10 of 20 sampled ED patients. ( Patient #7,#20, #4, #8, # 6, #31, #32, # 28,# 29,# 30). ED nursing staff failed to assess, monitor and evaluate patients to identify and respond to changes in patient conditions. The facility staff failed to ensure qualified staff were available to provide care and treatment for patients who arrived in the ED. The cumulative effects of these practices resulted in an unsafe environment for ED patients.

The findings included:

Review of the facility's "Emergency Department Triage Policy" Last Revised 11/2020 revealed "PURPOSE/SUPPORTING INFORMATION All patients presenting to the Emergency Department shall be evaluated by a Registered Nurse to determine the nature of their presenting complaints, their condition, and their priority for receiving a medical screening exam...PROCEDURE: A. Triage decisions are based on the 5 point Emergency Severity Index (ESI). B. Patients awaiting medical screening exam will be reassessed based on ESI or a minimum every 4 hours..Figure 2-2 ESI Triage Algorithm. v 4 Danger Vital Signs >8 yr ; Respiratory Rate > 20 consider ESI 2 High Risk Situation..."

1. Closed medical record review of Patient #7 revealed a 77 year old female who presented to the facility's emergency department with family on 06/06/2022 at 2031 for a arrival complaint of "Vomiting bile, watery stools, has rectal cancer, weakness, unable to stand x 2 days, loss of app (appetite) last had treatment last week on tue-thurs". Review revealed vital signs at 2043 blood pressure 87/53, pulse 67, respiratory rate 30, oxygenation 90%, Temperature 98.4. Review revealed at 2036 Patient Acuity: 3 (Urgent). Review revealed BP 118/55 at 2106. Patient #7 was placed in the ED waiting room awaiting treatment room assignment. Review revealed next documentation on 06/07/22 at 0200 " Spiritual Care and Assessment and Interventions: Reason for visit: Code Blue (life-saving measures)". Review revealed at 0204 on 06/07/2022 Code Start and Provider at bedside ( 4 hours and 58 minutes) since last assessment. Record review revealed Patient #7 was without a pulse and spontaneous respirations until 0220 on 06/07/2022. Review of ED Nursing note on 06/07/2022 at 0754 (late entry) revealed "This RN alerted to staff assist in intake room. Per triage RN, family notified staff for concern patient worsening. Patient was pulled into intake room to reassess vitals and notify MD. Shortly after, patient lost pulse and CPR (cardiopulmonary resuscitation) was initiated." Record review revealed ED Provider Note on 06/07/22 at 0233 revealed "History of Present Illness: 77 year old female who I am asked to see emergently as she is unresponsive. Upon my arrival to the room the patient has agonal respirations she is cyanotic, a [pulses] quickly lost and CPR (cardio pulmonary resussitation) is begun. She had had multiple rounds of CPR, and I ultimately spoke to family stated she has been here for approximately 6 hours, was increasingly weak, vomiting bile, unable to stand. Also apparently had a fever at home per report. She was told to come to the ED for evaluation. Her daughter noticed that she was unresponsive and not sleeping,she thinks she was unresponsive for approximately 5 minutes and then realized that she was not responding and asked for help. This is when I came to see the patient and initiated treatment..ED Course: ...I have discussed with family and planned for withdrawal of life support given her wishes if she continues to decline... 0401 The patient will be made comfortable anticipate her passing shortly.." Record review revealed Patient #7 pronounced deceased at 0425 on 06/07/2022.

Interview on 06/221/2022 at 1625 with RN (Registered Nurse) #34 revealed she recalled the Code Blue event on 06/07/2022. Interview revealed she arrived at Intake 6 and CPR was in progress. Interview revealed she started to document the events of the Code Blue. Interview revealed the MD (medical doctor) was at bedside when she arrived.

Interview on 06/22/2022 at 1030 with RN #35 revealed she was the triage nurse who assessed Patient #7. Interview revealed she received ESI training during orientation in August 2020. Interview revealed Patient #7 met ESI level 3 due to she was alert and oriented and was not actively vomiting. Interview revealed the EMT (Emergency Medical Technician) completed the vital signs and did not report any abnormal findings to her. Interview revealed Patient #7 did not need a reassessment for 8 hours after triage while waiting for treatment room placement.

Interview on 06/23/2022 at 1510 with EMT (Emergency Medical Technician) #36 revealed she recalled Patient #7 family member asking for help in the waiting room. Interview revealed Patient #7's husband was trying to wake her up and she was not responding. Interview revealed EMT #36 responded to assist and Patient #7 was unresponsive to pain with agonal respirations. Interview revealed she rolled her back to try and get vital sign abnd possibly got a heart rate of 29. Interview further revealed other staff went to get help as she took Patient #7 to Intake 6 where ED MD #37 arrived at same time and Code Blue was called.

Interview on 06/23/2022 at 0920 with ED MD #37 revealed he recalled Patient #7. Interview revealed he was asked to see an unconscious patient. Interview reveled he arrived to Intake 6 at the same time as the nursing staff with the patient. Interview revealed Patient #7 was unresponsive and pulseless upon his initial assessment. Interview revealed the nursing staff told him Patient #7 had a pulse. Interview revealed he never found a pulse on his assessment until after the Code Blue and CPR efforts began.

Interview on 06/23/2022 at 1557 with the ED Educator #13 revealed all nurses receive ESI training during orientation. Interview revealed ESI is a face to face and online class. Interview revealed ESI used to be an annual requirement until 2-3 years ago and currently is only required at hire. Interview revealed when presented with Patient #7 scenario, it was a high risk situation and meets ESI 2 criteria.

2. Closed medical record review of Patient #20 revealed a 95-year-old female who arrived at the facility on 06/13/2022 via EMS with a chief complaint of weakness. Review of the EMS run sheet revealed Patient #20 arrived at the facility at 2026. Review of the EMS run sheet revealed, " ...Upon arrival EMS was told that no bed were available and that it would be a bit of a wait. After talking to the Dr (doctor) to make sure that the 12-leads (EKG - electrocardiogram) were due to the possibility of the pt having low sodium/potassium crew went to wait. After a few Hr.(hours) crew check on the status of a bed and let the nurse know that the pt was suitable for triage, crew was informed that it would still be a wait. Crew still waiting on a bed after 9 hr (9 hours), crew has informed nurse multiple times that pt meets criteria for triage after speaking to the dr about 12-lead. Crew moved pt into wheelchair and move pt up to intake, transferred care to RN..." Review of the medical record revealed Patient #20 was accepted by facility staff on 06/14/2022 at 0652 (10 hours and 26 minutes after facility arrival). Medical record review revealed the MSE (medical screening exam) started at 0710. Review revealed a CAT Scan of the Head was ordered at 1036 and resulted at 1144. Review of the CAT Scan results at 1144 revealed, "... Impression: No acute intracranial abnormality..." Review of ED Note signed 06/14/2022 at 1207 revealed, "... Medical Decision Making and Plan: Patient emergency department with generalized weakness. Sodium and potassium are critically low. Started replacing here in the emergency department... 1000am: Patient had mentation change. Was ascus (sic) seen by the nurse. Patient noted to have some right-sided facial droop and does seem to be significantly confused. She is mildly dysarthric (weakness in the muscles used for speech, which often causes slowed or slurred speech)... Considering this acute change CT head ordered. Neurology consult for stat consult to determine whether not this is acute stroke... Neurology felt this likely secondary to be electrolyte abnormalities. Patient's mentation continues to be significantly altered. Hospitalist see has seen the patient and recommends ICU admission to the intensivist..." Review of the medical record revealed Patient #20 was admitted to the Intensive Care Unit on 06/14/2022 at 1602 with a diagnosis of Severe Hypokalemia and Severe Hyponatremia. Medical record review failed to reveal nursing documentation related to the reassessment of Patient #20 or documentation of her change in condition.

Interview on 06/28/2022 at 1415 with Paramedic #17 revealed she recalled the transport of Patient #20 on 06/13/2022. Interview revealed that the charge nurse stated that Patient #20 would have to wait until staff were available. Interview revealed that due to EKG concerns, Paramedic #17 consulted with the physician and was told Patient #20 was fine to wait for triage. Interview revealed at the time of handoff Patient #20 was stable.

Interview on 06/29/2022 at 0907 with RN #3 revealed that he was charge nurse on the night of 06/13/2022. Interview revealed RN #3 did not recall Patient #20. Interview revealed that staff were expected to assess their patients per policy and document what they perform.

Interview on 06/23/2022 at 1025 with the ED Director #14 revealed the facility had staffing challenges which impacted the availability of staff to meet patient needs. Interview revealed the expectation of nursing staff was to follow the facility policy regarding assessments and reassessments.

3. Closed medical record review of Patient #4 revealed a 4-year-old male who arrived at the ED on 06/13/2022 at 2106 via private vehicle. Record review revealed the chief complaint was a laceration to the back of the head. Medical record review revealed Patient #4 was triaged at 2107 and vital signs performed at 2120 were as follows: Temperature - 98.2F, Heart Rate - 155, Oxygen Saturation - 98%, Respirations - 36, Weight - 39 lbs., 3.2oz, and Blood Pressure - (Unable to obtain d/t (due to) crying screaming). A pain assessment was not documented. Medical record review revealed Patient #4 was placed in the lobby with his parents to wait. Record review revealed the Medical Screening Exam (MSE) was performed on 06/14/2022 at 0734. Additional vital signs were obtained at 0923: Temperature - 98.4F, Heart Rate - 132, Oxygen Saturation - 100%, Respirations - 20, Pain - denies (12 hours and 3 minutes after the first vital sign assessment). Medical record review revealed Patient #4 was discharged home on 06/14/2022 at 0924 with his parents. Medical record review failed to reveal the reassessment of the patient on a four-hour interval before his MSE was performed (0100, 0500 missing reassessments).

Interview on 06/22/2022 at 1415 with RN #32 revealed he recalled caring for Patient #4 on the morning of 06/14/2022. Interview revealed the family had been waiting all night, so he got supplies set up for the provider and performed a set of discharge vitals after the staples were done on the head laceration. Interview revealed that vital signs were to be performed on a four-hour interval for patients awaiting an MSE.

Interview on 06/23/2022 at 0930 with RN #33 revealed she recalled performing the triage on Patient #4. Interview revealed that the protocol for monitoring in the waiting room was every four hours. Interview revealed that depending on staffing and patient volumes, it was challenging to reassess and monitor patients waiting for their MSE every four hours.

Interview on 06/23/2022 at 1025 with the ED Director #14 revealed the expectation of nursing staff to follow the facility policy regarding assessments and reassessments. Interview revealed nursing staff should have performed vital signs at minimum every 4 hours on all patients waiting to have their MSE.



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Observation on 06/21/2022 at 1155 during facility tour revealed the Emergency Department (ED) had 108 beds, up to 200 spaces when hallway beds were included. Observation revealed the ED currently had 138 patients in the unit. 64 patients were inpatient status and waiting for bed placement. Observation revealed the current number of nursing staff was 13.

Observation on 06/29/2022 at 1330 during facility tour revealed the ED had 111 patients in the unit. 53 patients were inpatient status and waiting for bed placement. Observation revealed the current number of nursing staff was 20.

Review of the facility policy, "Patient Bill of Rights and Responsibilities" effective 01/2020, revealed, " ...The patient has the right to expect emergency procedures to be implemented without unnecessary delay ..."

Review of the ED staffing plan revealed the staffing pattern for 108 bedded patients resulted in 25 RNs and 14 Paramedic/ ED Techs.

4. Open medical record review of Patient #8 revealed a 53-year-old male patient who arrived at the facility on 06/20/2022 via EMS (emergency medical services) with a chief complaint of agitation. Review of the EMS run sheet revealed Patient #8's facility arrival was at 1940. Review of the EMS run sheet revealed, " ... 1942 - Medical Consult: (named paramedic) consulted with (named ED physician) via In Person. PT (patient) increasingly agitated and confused. Additional sedation needed ... 1954: Heart Rate - 96, Blood Pressure - 169/97, Oxygen Saturation - 100%, Respirations - 28 ... 2000: Lorazepam (Sedative, commonly used for seizures or anxiety) 2 MG (milligram) via IV (intravenous) Push... Pt. response: unchanged... Haloperidol (Antipsychotic, commonly used for mental/mood disorders) 15 MG via IV Push... Pt response: unchanged... 2010: Heart Rate - 102, Blood Pressure - 172/100, Oxygen Saturation - 100%, Respirations - 30 ... 2030: Ketamine (Anesthetic, commonly used for sedation), 400 MG via IM (intramuscular)... Pt response: improved... 2035: Heart Rate - 120, Blood Pressure - 181/102, Oxygen Saturation - 97%, Respirations - 26 ... 2040: A pt care report was given and care of the pt was transferred to the receiving RN staff ..." Review of the EMS run sheet revealed that Paramedic #15 administered the Lorazepam, Haloperidol, and Ketamine medications per the verbal order of MD# 11 while waiting in the ED hallway. Review of the medical record revealed Patient #8 was accepted by the facility ED staff at 2036 (56 minutes after facility arrival). Medical record review revealed the MSE (medical screening exam) started at 2039 and Patient #8 was subsequently sedated and intubated at 2207. Review of the medical record revealed Patient #8 was admitted to the Intensive Care Unit on 06/20/2022 at 2316 with a diagnosis of Acute Toxic Metabolic Encephalopathy. Medical record review revealed qualified personnel was not available to meet the emergent needs of Patient #8 upon facility arrival at 1940 for 56 minutes creating an unsafe setting for patient care.

Review of the Staffing Report for the ED cost center for 06/20/2022 at 2000 revealed: 1 RN - ED, 4 RNs - BHU (behavioral health), 10.75 RNs - IP (inpatient). Review revealed inpatient nurses cared for ED patients in their assignments.

Review of the EMR (electronic medical record) Patient Volumes Report for 06/20/2022 at 2000 revealed: ED Patients - 60, Behavioral Health - 28, Inpatient (Patients admitted to the facility but housed within the emergency department) total - 63. Review revealed a total of 151 patients being cared for within the emergency department.

Interview on 06/22/2022 at 1318 with Paramedic #15 revealed that he provided care for Patient #8 on 06/20/2022. Interview revealed Patient #8 was agitated and did not follow verbal commands. Interview revealed that when the EMS team arrived at the facility they were advised to wait in the hallway until staff were available to receive handoff report. Interview revealed Paramedic #3 consulted with MD #2 due to Patient #8's increased agitation in the hallway. Interview revealed MD #2 gave Paramedic #3 verbal orders for sedation medication. Interview revealed the medications were administered in the hallway and shortly afterwards Patient #8 was placed into a room. Interview revealed the facility staff took over care of Patient #8 and began his triage and medical screening exam after the administration of the medication in the hallway. Interview revealed that the availability of ED staff to meet the needs of patients upon facility arrival varied heavily based on facility staffing.

Interview on 06/23/2022 at 0947 with RN #3 revealed he was the charge nurse on the night of 06/20/2022. Interview revealed RN #3 was notified by EMS that Patient #8 required medication to decrease his agitation. Interview revealed EMS requested the use of a patient room instead of remaining in the hallway while waiting to handoff to facility staff. RN #3 revealed the nursing staff did not assume care of the patient until after report was received from EMS, which varied from minutes to hours after facility arrival.

Interview request for the RN assigned to Patient #8 on the night of 06/20/2022 revealed she was unavailable for interview.

Interview on 06/23/2022 at 1025 with the ED Director #14 revealed the facility had recently averaged 40-70 inpatients holding in the emergency department while caring for the emergency patients. Interview revealed the facility had staffing challenges which impacted the availability of staff to meet patient needs. Interview revealed the expectation for EMS offloading time was 30 minutes. Interview revealed ED staff were expected to accept the patient within 30 minutes of arrival to the facility. Interview revealed that the department had experienced longer wait times and decrease in satisfaction scores due to staffing issues.

Interview on 06/24/2022 at 1230 with the Nurse Manager #16 revealed that the facility had created roles to assist with offloading the patients from EMS staff, but it relied on staffing availability. Interview revealed that staffing the ED with qualified professionals like RNs, Paramedics, and ED Techs to meet the patient needs was a challenge and had impacted the level of care that patients received. Interview revealed that ED staff commonly took assignments with inpatients or behavioral health patients while caring for emergency patients.

Interview on 06/23/2022 at 0852 with MD #11 revealed he was the ED provider for Patient #8 on 06/20/2022. Interview revealed MD #11 recalled the discussion with EMS about Patient #8's agitation and the verbal orders for medication. Interview revealed that providers gave EMS orders to carry out in the hallway before the patients were triaged or assessed by the facility staff. Interview revealed that due to the patient volume and staff constraints, the providers use whatever resources they have available like EMS paramedics giving medications in the hallway.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement. Interview revealed the providers gave EMS staff orders for hallway patients prior to triage and room placement.



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5. A closed medical record review of Patient #6 revealed an 83-year-old female who arrived at the facility on 06/13/2022 via EMS (emergency medical services) with a chief complaint of increased confusion. A review of the EMS run sheet revealed Patient #6 arrived at the facility at 0416. The review of the EMS run sheet revealed, "...Pt (patient) transported to named facility ED (emergency department) hallway, report given to Named RN (Registered Nurse) charge nurse who requested a doctor to check pt out for triage purposes. Dr (doctor) came to stretcher to assess pt and states she does not meet stroke criteria and states pt will have to wait for room and orders for CT (computerized tomography) and labs. ...Crew wants to make the ED aware that pt has new onset immobility in lower ext (extremities) and daughter states she is not behaving normally. ER (emergency room) doctor was not concerned ..." A review of the medical record revealed the facility documented Patient #6 arrived on 06/13/2022 at 0851 (4 hours and 35 minutes after the patient's actual arrival). The medical record review revealed the MSE (medical screening exam) started at 0902 and the patient was subsequently admitted on 06/13/2022 at 2016 with a diagnosis of AMS (altered mental status). The medical record review revealed qualified personnel was not available to meet the needs of Patient #6 upon facility arrival at 0416 for 4 hours and 35 minutes.

An interview on 06/23/2022 at 1025 with ED Director #14 revealed the facility had recently averaged 40-70 inpatients holding in the emergency department while caring for the emergency patients. The interview revealed the facility had staffing challenges that impacted the availability of staff to meet patient needs. The interview revealed the expectation for EMS staff offloading and ED staff accepting the patient was 30 minutes. The interview revealed that the department had experienced longer wait times and a decrease in satisfaction scores due to staffing issues.

An interview on 06/24/2022 at 1230 with Nurse Manager #16 revealed that the facility had created roles to assist with offloading the EMS staff, but it relied on staffing availability. The interview revealed that staffing the ED with qualified professionals like RNs, Paramedics, and ED Techs to meet the patient needs was a challenge and had impacted the level of care that patients received. The interview revealed that ED staff commonly took assignments with inpatients or behavioral health patients while caring for emergency patients.

Telephone interview on 06/28/2022 at 1500 with Paramedic #24 revealed she was one of the EMS providers that took care of Patient #6. Interview revealed Paramedic #24 received report from off going EMS staff. Interview revealed while waiting and monitoring Patient #6 to get an ED bed, Paramedic #24 transported Patient #6 to CT scan with hospital staff. Interview revealed an ED nurse gave Patient #6 IV medication prior to Paramedic #24 taking the patient to CT scan. Interview revealed Paramedic #24 and Patient #6 had to wait in the hallway outside the radio room for hours until an ED bed became available.

An interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. The interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

Telephone interview on 06/29/2022 at 1517 with Paramedic #25 revealed she transported Patient #6 to the ED. Interview revealed Patient #6's daughter reported Patient #6 normally walks and after dinner Patient #6 started leaning to one side when she was sitting upright. Interview revealed Patient #6 could not sit upright without leaning to the side. Interview revealed when EMS arrived in the ED, Paramedic #25 gave report to the triage nurse who was concerned about Patient #6. Interview revealed the triage nurse got a doctor to evaluate Patient #6. Interview revealed after the doctor evaluated Patient #6, Paramedic #25 waited with Patient #6 to get an ED bed. Interview revealed Patient #6 went from acting sweet to acting ugly and took off all her clothing. Interview revealed Paramedic #25 updated the triage nurse on the change in condition. Interview revealed Paramedic #25 was worried about the neurologic state of Patient #6 with the sudden change. Interview revealed Paramedic #25 handed Patient #6 off to the oncoming EMS crew at the end of her shift. Interview revealed Paramedic #25 estimated she monitored Patient #6 from around 0300 to 0800 when the next EMS crew took over. Interview revealed the EMS run sheet would have the exact times, but this was a rough estimate.



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6. Closed medical record review of Patient # 31 revealed a 92 year old female who presented to the facility's emergency department via EMS on 05/31/2022 at 1722 for a chief complaint of syncope. Review of the EMS patient care report revealed Patient #31 was alert and oriented with a BP of 132/89, pulse 81, respiratory rate 18. Review of EMS patient care report revealed "EMS arrives at receiving. One EMS crew member went into receiving to register patient. Triage notified EMS as long as patient had mask on patient could come inside to stage in hallway. With mask in place on patient, patient was transferred into receiving. EMS asked to stage in hallway until room became available. During wait time patient was assisted to bathroom. While waiting for room patient slept on stretcher. After extensive wait time, EMS asked triage if patient could be triaged due to patients stability and that there were ALS (advanced life support) interventions at that time. Triage nurse declined sitting she did not want patient to sit in the lobby with family due to syncopal episode as patient's chief complaint, Charge nurse was consulted and she advised patient could not be triaged for same. EMS notified the wait time could extend another 9 hours possibly. Patient and family were advised of further extended wait times. Patient and patient's family decided to take patient to another facility for treatment. Another set of vital signs were obtained, refusal..explained to them... EMS assisted patient transferring from wheelchair to front seat of POV (privately owned vehicle)." Patient #31 signed an EMS Refusal releasing them from EMS care. Review revealed Patient left EMS care at 2110. Review revealed patient care was never transferred to emergency department personnel and Patient #31 left the facility with family after waiting 3 hours and 48 minutes.

Interview on 06/29/2022 at 1015 with Paramedic #38 revealed she was the EMS personnel who transported Patient #31 to the emergency department. Interview revealed the patient's vital signs were stable and she was capable to sit in triage with family to prevent in a delay in triage. Interview revealed no nursing staff triaged the patient while waiting. Interview revealed revealed the emergency department staff say "she's your patient, she's in your care until we take report". Interview revealed the family was tired of waiting and wanted to take the patient to another hospital. Interview revealed EMS personnel made the charge nurse aware and the hospital staff do not speak to the patient's prior to departure. EMS staff assisted the patient to family's car.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

Interview on 06/24/2022 at 1250 with the previous Emergency Department Administrative Coordinator revealed when a patient voices a desire to leave the emergency department without completing treatment or a medical screening exam, a written refusal is attempted and risks and benefits are explained to the patient. Interview revealed the charge nurse is made aware and notifies the the physician. Interview revealed patients waiting with EMS staff for triage and room placement should also have a written refusal by emergency department staff prior to leaving the facility.

7. Closed medical record review of Patient #32 revealed a 67 year old female who presented to the facility's emergency department on 06/09/2022 at 1408 via EMS for a chief complaint of chest pain. Review of EMS patient care report revealed at 1408 "....Pt (patient) registered and report given to the triage nurse. No significant changes in pt condition while waiting for bed..." Review revealed at 1530 BP 102/57, pulse 72, oxygenation 94% and respiratory rate 12. Further review revealed at 1620 "Pt began complaining of increased r (right) sided chest pain radiating to her r arm. Nitroglycerin (medication used to treat chest pain), .4 MG via SL (sublingual) given (by named EMS Staff member)... Authorization:via Protocol. Pt response: Improved..." EMS report review revealed at 1908 "Pt stating she would like to leave ER AMA (against medical advise). Pt advised of possible consequences if leaving before being seen by a doctor. Pt verbalized understanding of possible consequences and signature obtained.." Record review revealed Patient #32 signed EMS refusal (5 hours after arrival). Review of facilty emergency department medical record revealed Patient #32 disposition set at 2043 "LWBS (left without being seen) before triage" and discharged at 2044.

Interview on 06/29/2022 at 1215 with Paramedic # 39 revealed he recalled Patient # 32. Interview revealed EMS staff had to treat the patient due to the complaint of chest pain. Interview revealed they have treatment protocols. Interview revealed the patient was tired of waiting. Interview revealed the ED staff never attempt to get a refusal of treatment from a patient waiting with EMS staff. Interview revealed he did notify ED staff Patient #32 was wanting to leave but they did nothing because Patient #32 was "still under the care of EMS staff in the hallway".

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

Interview on 06/24/2011 at 1250 with the previous Emergency Department Administrative Coordinator revealed when a patient voices a desire to leave the emergency department without completing treatment or a medical screening exam, a written refusal is attempted and risks and benefits are explained to the patient. Interview revealed the charge nurse is made aware and notifies the the physician. Interview revealed patients waiting with EMS staff for triage and room placement should also have a written refusal by emergency department staff prior to leaving the facility.

8. Closed medical record review revealed Patient #28 was a 76-year-old male brought to the emergency department (ED) by emergency medical service (EMS) on 05/23/2022 with a complaint of vomiting. Review of the EMS run report revealed EMS arrived in the ED with Patient #28 at 2052. Review of the ED Timeline revealed the hospital documented Patient #28's arrival in the ED as 0139 (4 hours 47 minutes after EMS arrived with the patient). Review revealed the ED disposition was set to "LWBS before Triage" at 0142 (4 hours 50 minutes after EMS arrived with the patient). Review of the medical record revealed no MSE and no documentation of risk and benefits were discussed with Patient #28 by hospital staff prior to him leaving the ED.

Telephone interview on 06/28/2022 at 1359 with Paramedic #28 revealed he transported Patient #28 to the ED. Interview revealed when they arrived in the ED there were already 3 or 4 other EMS with stretchers with patients waiting to be seen. Interview revealed Paramedic #28 checked in with the triage nurse. Interview revealed a hospital staff member came to the stretcher and asked Patient #28 questions and then put a wrist band on the patient. Interview revealed after five hours waiting and not being see or evaluated, Patient #28 decided she was going to leave. Interview revealed Paramedic #28 notified the charge nurse of Patient #28 wanting to leave. Interview revealed the charge nurse notified Paramedic #28 the patient (Patient #28) did not need to sign anything for the hospital because they were not a patient of the hospital. Interview revealed Paramedic #28 had Patient #28 sign an EMS Refusal releasing them from EMS care. Interview revealed the hospital front desk staff called a taxi for Patient #28 to leave.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patien

Based on facility policy review, medical record review, and staff interview, the facility staff failed to identify the use of chemical restraints in 2 of 2 chemically restrained patient records sampled (Patient #8, 23).

The findings included:

Review of the facility policy, "Restraint Use for Adults and Children" effective 06/2021, revealed, "... Definitions: ...[A restraint is] Any drug or medication when it is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's medical condition... "

Review on 06/29/2022 of "Physician and APP (advanced practice provider) Education" dated 2022, failed to reveal education related to chemical restraints.

Review on 06/29/2022 of "RN Restraint Safety Learning Module" dated 2022, revealed, "... What is considered a restraint? ... A restraint is also a drug or medication when it is used as a restriction to manage the patient's behavior, or restrict the patient's freedom of movement, and is not a standard treatment or dosage for the patient's condition. (named facility) does not advocate the use of drugs used as a restraint..."

Review on 06/29/2022 of Restraints QAPI failed to reveal documentation of chemical restraints within the past year.

1. Open medical record review on 06/21/2022 of Patient #8 revealed a 53-year-old male patient who arrived at the facility on 06/20/2022 at 1940 via EMS (emergency medical services) with a chief complaint of muscle spasms (electric like pain) shooting through legs and arms. Review of the EMS run sheet revealed, "Pt(patient) was sitting upright on end of the bed in his hotel room. Pt was A&O (alert and oriented) upon EMS arrival however was jerking, shaking, and flexing his arms and legs uncontrollably... Pt reported that he was working out at the hotel... Pt reported that he had just taken his newly prescribed Naltrexone 30-45 minutes before these symptoms started. Pt denied any alcohol or drug use... 1905 - Diphenhydramine (Benadryl - antihistamine) 50 MG IV given... 1925 - Diazepam (valium) 10 MG IV given.... 1940 - Facility Arrival... 1942 - Medical Consult: (named paramedic) consulted with (named ED physician) via In Person. PT (patient) increasingly agitated and confused. Additional sedation needed... 1954: Heart Rate - 96, Blood Pressure - 169/97, Oxygen Saturation - 100%, Respirations - 28 ... 2000: Lorazepam (Sedative, commonly used for seizures or anxiety) 2 MG (milligram) via IV (intravenous) Push given by (named paramedic) ... Pt. response: unchanged. Given per (named ED physician) ... Haloperidol (Antipsychotic, commonly used for mental/mood disorders) 15 MG via IV Push given by (named paramedic) ... Pt response: unchanged. Given per (named ED physician) ... 2010: Heart Rate - 102, Blood Pressure - 172/100, Oxygen Saturation - 100%, Respirations - 30 ... 2030: Ketamine (Anesthetic, commonly used for sedation), 400 MG via IM (intramuscular) given by (named paramedic) ... Pt response: improved. Given per (named ED physician) ... 2035: Heart Rate - 120, Blood Pressure - 181/102, Oxygen Saturation - 97%, Respirations - 26 ... 2040: A pt care report was given and care of the pt was transferred to the receiving RN staff ..." Review of the medical record revealed Patient #8 was arrived and triaged at 2036 (56 minutes after facility arrival). Review of the Focused Assessment at 2036 revealed, "... Level of Consciousness: Alert (Agitated and Confused)..." Medical record review revealed the MSE (medical screening exam) started at 2039. Patient #8's vital signs at 2040 were: Heart Rate - 108, Blood Pressure - 170/100, Oxygen Saturation - 100%, Respirations - 22. Medical record review revealed Patient #8 received Ativan 2 MG via IV at 2133. Review of the Neurological Assessment at 2144 revealed, "... Neuro: Unchanged (Pt agitated and confused) Level of Consciousness: (Agitated and combative, does not respond to verbal stimuli, placed in restraints. combative)..." Patient #8's vital signs at 2200 were: Heart Rate - 121, Oxygen Saturation - 97%, Respirations - 30. Patient #8 was subsequently sedated and intubated at 2207. Review of the Medical Screening Exam signed 06/20/2022 at 2322 revealed, "... ED Course & Medical Decision Making... Patient presents emergency department with acute agitation. EMS could not control patient's symptoms at home and transported patient for further evaluation. I would not expect one dose of naltrexone to be causing all of his symptoms. I have ordered IM Ketamine to facilitate workup and hopefully control symptoms somewhat. 21:19 After IM Ketamine, patient seemed to be resting a bit more comfortably. I was then called back to the bedside. Patient becoming a bit more agitated. At this point patient has been given Haldol 15 milligrams IV, Ketamine 400 mg IM, Valium 10 milligrams, Benadryl 50 milligrams IV, Ativan 2 milligrams IV. Patient has been maintaining his airway. No vomiting. Patient will be given 2 milligrams IV a second time. He will be monitored closely. If we cannot get his agitation under control, could consider intubation. Patient noted to be hypertensive, mildly tachycardic. labs pending... 2152... patient now requiring restraints... Agreed with intubation for airway protection to facilitate workup as well... 22:43 Urine drug screen noted... Urinalysis fairly unremarkable... Patient requiring repeat doses of fentanyl as he is trying to self extubate despite being in restraints... Final Impression: Altered mental status, Early rhabdomyolysis..." Review of the medical record revealed Patient #8 was admitted to the Intensive Care Unit on 06/20/2022 at 2316 with a diagnosis of Acute Toxic Metabolic Encephalopathy. Medical record review revealed the adminstration of chemical restraints prior to the triage, medical screening exam, or initiation of a plan of care. Medical record review failed to reveal documentation that the facility identified the use of Ativan, Lorazepam, or Ketamine as chemical restraints.

Interview on 06/23/2022 at 0947 with RN #3 revealed, "We (facility) don't do chemical restraints." Interview revealed that chemical restraints were not in the facility's restraint policy. Interview revealed the facility only performed violent and non-violent physical restraints.

Interview on 06/29/2022 at 1325 with RN #4 revealed he received training on restraints. Interview revealed that chemical restraints were used to sedate patients, like Benzodiazepine and Haldol, or chemically impair the patient.

Interview on 06/29/2022 at with RN #5 revealed chemical restraints were not used unless they tried other alternatives first. Interview revealed that chemical restraints were medications given to sedate the patient. Interview revealed the facility had a high population of psychiatric patients and they got medication for agitation.

Interview on 06/27/2022 at 1342 with Pt. Safety #6 revealed chemical restraints were considered violent restraints. Interview revealed chemical restraints have to be ordered as chemical restraints in order to populate on the daily restraints' reports. Interview revealed that chemical restraints were medications like Haldol or Geodon, but the facility tried not to use medications as a restraint.

Interview on 06/27/2022 at 0158 with the CNO #7 revealed she could not recall the last time that chemical restraints were administered at the facility. Interview revealed chemical restraints were medications that were used so that the patient can participate in their care. Interview revealed the Physician made the decision on whether the medications were considered chemical restraints. Interview revealed nursing staff received training on chemical restraints on hire and annually.

Interview on 06/27/2022 at 1529 with the VP for Behavioral Health #8 revealed the facility staff defined chemical restraints as medication not used for the intention of treating symptoms. Interview revealed chemical restraints were rarely used at the facility. Interview revealed psychiatric patients were not chemically sedated; they were medicated to participate in their plan of care.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 and CMO #10 revealed that chemical restraints were medications used to sedate patients to reduce the patient's participation in their plan of care. Interview revealed that the medications that were prescribed were to modify behavior so that the patient could participate in their plan of care. Interview revealed the Ativan, Lorazepam, and Ketamine administered to Patient #8 were not considered chemical restraints.

2. Open medical record review on 06/27/2022 for Patient #23 revealed a 41-year-old female who arrived at the facility on 06/26/2022 at 1719 via EMS with a chief complaint of Altered mental Status, Involuntary Commitment (IVC). Review of the Chief Complaint at 1902 revealed, "Altered Mental Status (The patient was involved in a non-injury MVC (motor vehicle collision), sts (states) she 'blacked out' due to PTSD (post-traumatic stress disorder) and walked back to her house, and husband stated that she had been altered as well." Review of the Medical Screening Exam dated 06/26/2022 at 1911 revealed, "... Current Medications - Multivitamins, Ativan 1 MG, Zolpidem (Ambien) 5 MG..." Medical record review revealed Patient #23 was medically cleared by the physician and moved to the Behavioral Health area to await a Psychiatric Exam at 2049. Review of the Psychiatric Medical Screening Exam dated 06/27/2022 at 0012 revealed, "... Any emergency measures required since arriving in ED: medication given by RN due to inappropriate behaviors..." Review of the ED Notes dated 06/27/2022 at 0141 revealed, "... Earlier in the shift patient attempted to leave ED x 2 (two times)... At 2353, pt noted to get up and began to run to room 40. She threw closed the curtain, and while staff were telling her to stop, she jumped on top of a male pt straddling him. She immediately was told to get off pt. (named physician) was made aware and new orderes (sic) received. Pt was given Geodon 20 mg at 2353. When asked why she got on top of patient, pt aware of her behavior but states she does not know why. States I know I need to be IVC now. Patient has remained cooperative sine (sic) medication given and is a sleep (sic) at this time..." Review of the Medication Administration Record revealed Geodon 20 MG given on 06/26/2022 at 2353. Review of ED Notes dated 06/27/2022 at 1348 revealed, "Writer observed patient climb on top of another patient, the same patient she did last night, and straddle him. Company police and sitters provided redirection and patient returned to assigned bed... Patient then began talking very loudly and threw the Ensure she requested on the ground 'because it didn't taste good'... De escalation (sic) attempted by RN and company police but was unsuccessful. 5 MG IM Haldol willingly given at 1345. Patient continues to yell and disturb other patients, she went up to a patient stating 'your hair is on fire.' Patient would not elaborate if she was experiencing visual hallucinations at the time. Patient is speaking with a flight of ideas and disorganized speech. Previous medication appears ineffective as patient is agitated with psychomotor restlessness, gesturing, and yelling present. (named physician) notified and medication orders obtained for acute agitation. 5 MG IM Haldol, 50 MG IM Diphenhydramine, 5 MG IM Valium administered at 1417..." Medical record review failed to reveal documentation that the facility identified the use of Geodon, Haldol, Diphenhydramine, or Valium as chemical restraints.

Interview on 06/23/2022 at 0947 with RN #3 revealed, "We (facility) don't do chemical restraints." Interview revealed that chemical restraints were not in the facility's restraints policy. Interview revealed the facility only performed violent and non-violent physical restraints.

Interview on 06/29/2022 at 1325 with RN #4 revealed he received training on restraints. Interview revealed that chemical restraints were used to sedate patients, like Benzodiazepine and Haldol, or chemically impair the patient.

Interview on 06/29/2022 at with RN #5 revealed chemical restraints were not used unless they tried other alternatives first. Interview revealed that chemical restraints were medications given to sedate the patient. Interview revealed the facility had a high population of psychiatric patients and they got medication for agitation.

Interview on 06/27/2022 at 1342 with Pt. Safety #6 revealed chemical restraints were considered violent restraints and would be monitored the same. Interview revealed chemical restraints have to be ordered as chemical restraints in order to populate on the daily restraints' reports. Interview revealed that chemical restraints were medications like Haldol or Geodon, but the facility tried not to use medications as a restraint.

Interview on 06/27/2022 at 0158 with the CNO #7 revealed she could not recall the last time that chemical restraints were administered at the facility. Interview revealed chemical restraints were medications that were used so that the patient can participate in their care. Interview revealed the Physician made the decision on whether the medications were considered chemical restraints. Interview revealed nursing staff received training on chemical restraints on hire and annually.

Interview on 06/27/2022 at 1529 with the VP for Behavioral Health #8 revealed the facility staff defined chemical restraints as medication not used for the intention of treating symptoms. Interview revealed chemical restraints were rarely used at the facility. Interview revealed psychiatric patients were not chemically sedated; they were medicated to participate in their plan of care.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 and CMO #10 revealed that chemical restraints were medications used to sedate patients in order to reduce the patient's participation in their plan of care. Interview revealed that the Geodon, Haldol, Diphenhydramine, and Valium that were administered to Patient #23 were to modify behavior so that the patient could participate in their plan of care.

Based on policy review, medical record review, and staff interview, the facility staff failed to document a physician's order for restrictive interventions in 1 of 2 violent restraint records reviewed (Patient #8).

The findings included:

Review of the facility policy, "Restraint Use for Adults and Children" effective 06/2021, revealed, "... 3. Orders: - The Physician/LIP (licensed independent practitioner) is responsible for ordering a time limited use of restraint intervention after an assessment of the patient... - All orders for restraints must: ... - Be documented in the electronic medical record..."

Review of the facility policy, "Telephone or Verbal Orders" effective 03/2021, revealed, "... A. The individual taking a verbal or telephone order must enter the order into the electronic medical record promptly..."

Open medical record review on 06/21/2022 of Patient #8 revealed a 53-year-old male patient who arrived at the facility's Emergency Department (ED) on 06/20/2022 via EMS (emergency medical services) with a chief complaint of agitation. Review of the Neurological Assessment by RN #3 at 2144 revealed, "... Pt(patient) agitated and confused... Level of Consciousness: (Agitated and Combative, Does not respond to verbal stimuli, Placed in restraints. Combative.)... Incomprehensible speech..." Review of Safety Violent or Self-Destructive Restraints documentation at 2146 revealed, "... 4-point restraints/Neoprene and Physical Hold for Restraint Application Only: Start..." Review of Safety Violent or Self-Destructive Restraints documentation revealed that Patient #8 was monitored on a 15-minute interval at: 2200, 2215, 2230, 2245, 2300. Record review revealed the violent restraints were discontinued at 2305. Review of the medical record revealed Patient #8 was admitted to the Intensive Care Unit on 06/20/2022 at 2316. The medical record review failed to reveal a provider order for the use of violent restraints.

Review of a Physician Order Screenshot presented by Pt Safety #6 on 06/28/2022 at 1617 revealed a Violent Restraint order. Review revealed the Violent Restraint order was entered into the electronic medical record by RN #3 on 06/22/2022 at 2043 (1 day and 22 hours after the restraints started), cosigned by an inpatient physician (not MD #11) on 06/28/2022 at 0905 (7 days and 11 hours after the restraints started).

Interview on 06/23/2022 at 0947 with RN #3 revealed he was present at the time the violent restraints were verbally ordered. Interview revealed Patient #8 was difficult to physically manage and agitated. Interview revealed RN #3 felt Patient #8 was going to injure himself and others due to his behavior. Interview revealed RN #3 got a verbal order from MD #11 and the neoprene restraints were applied. Interview revealed the violent restraint order was not entered into the electronic medical record during the shift when the verbal order was given.

Interview on 06/23/2022 at 0852 with MD #11 revealed he provided care for Patient #8 in the Emergency Department on 06/20/2022. Interview revealed Patient #8 was agitated and "altered". Interview revealed MD #11 gave a verbal order for the violent restraints to maintain the safety of the patient. Interview revealed the nursing staff enter the verbal order and the provider cosigns the order later.

Interview on 06/23/2022 at 1610 with the ED Educator #13 revealed ED staff received training on restraints. Interview revealed ED staff were trained to obtain a physician order for all restraints. Interview revealed that when verbal orders were received by nursing staff, the nurse entered the order into the electronic medical record and the physician cosigned it.

Interview on 06/23/2022 at 1025 with the ED Director #14 revealed the expectation of nursing staff was to enter verbal orders timely and follow facility policy on restraints.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed the medical providers were expected to cosign their verbal orders in 24 hours. Interview revealed if the verbal order was not entered into the electronic medical record, then the physician would not know that the ordered needed to be cosigned.

Based on review of the facility's Quality Assurance and Performance Improvement Program plan, process improvement documents, EMS turn around time data, medical record reviews, observations, and staff interviews, the hospital failed to maintain an effective on-going Quality Assessment and Performance Improvement program for patient safety.

The findings include:

Based on review of the facility's Quality Assurance and Performance Improvement Program plan, process improvement documents, EMS turn around time data, medical record reviews, observations, and staff interviews, the facility staff failed to collect accurate turn-around-time data and implement performance improvement measures to decrease EMS turn-around-times within the Emergency Department.

~cross refer to 482.21(b)(2)(ii),(c)(1),(c)(3) Standard: QAPI Quality Improvement Activities, Tag A0283

Based on review of the facility's Quality Assurance and Performance Improvement Program plan, process improvement documents, EMS turn around time data, medical record reviews, observations, and staff interviews, the facility staff failed to collect accurate turn-around-time data and implement performance improvement measures to decrease EMS turn-around-times within the Emergency Department.

The findings included:

Review on 06/29/2022 of the QAPI (Quality Assurance and Performance Improvement Program) approved on 04/12/2022 revealed "...The purpose of this plan is to provide for the development, implementation and maintenance of an effective Quality Assurance and Performance Improvement Program ...ACTIVITIES OF THE QUALITY ASSURANCE AND PERFORMANCE PROGRAM: ...Prioritize data collection efforts ...Sponsor changes to improve quality, including patient outcomes, safety and service excellence ... Evaluate the effectiveness of improvements ...DATA COLLECTION, ANALYSIS AND PERFORMANCE IMPROVEMENT ...The organization collects data to monitor the stability of existing high priority and required processes, to identify opportunities for improvement, to identify changes that lead to improvement, or those that sustain improvement ...Improvement Methodology: ...The organization will act on improvement priorities by designing new processes or redesigning existing processes..."

Review on 06/29/2022 of "Flow and Throughput Process Improvement Timeline," first entry dated October 2021 revealed in October, 2021 an "EMS [emergency medical services] Turnaround Time" worksheet revealed "Issue: There is a delay in EMS turnaround time at the ED [emergency department] on 17th St. [street]" (Address of named hospital). Review revealed the facility identified the concern of EMS turnaround time in October 2021, and metrics to be measured included: EMS turnaround time (from EMS arrival to RN [registered nurse] handoff) and Outliers > 90 minutes. "Background information/ Baseline data: Turnaround times now average 65 minutes." Review of "Tactic: 'Arrive' in Epic [computer program name] at true time of arrival" revealed "Steps: Looking for resources to 'arrive' EMS patients." Review revealed no update was listed. Review of "Tactic: Staffing Redesign" revealed "Steps: labor market assessment tool approval to be completed by 02/25/2022. No further status updates were provided. Review of the data collected did not reflect the actual arrival time of the patients via EMS. The data collected was based on the time the nurses accepted the patients from EMS staff regardless of actual arrival time to the facility. Review revealed inaccurate data collection of patients presenting to the ED via EMS.

Review of the "Patient Flow Application" overview, no date provided, revealed "RNs don`t want to take report (EMS TAT [turnaround time] 62 minutes)." Review revealed the turnaround time average for October,2021 was 65 minutes and for May,2022 the average was 62 minutes. Review revealed "Actions: Review staffing ...Add provider 7a- 3a [ in front lobby], Add paramedics [in front lobby], Add phlebotomist [for inpatient boarders], Add bed traffic controller." Review revealed no significant improvement or actions taken to improve identified EMS turnaround times from 10/2021 through 05/30/2022.

Review on 06/29/2022 of a schedule for redeploying non-clinical staff to assist in clinical areas initiated on 06/13/2022 revealed 161 shifts had been accepted by the non-clinical staff for non-emergency department areas within the hospital. Review revealed 25 shifts had been accepted by the non-clinical staff for the emergency department within the hospital.

Interview on 06/27/2022 at 1408 with the Performance Improvement Coordinator for Emergency Services revealed all data collected for the identified process improvement for the emergency department reflected the time the nurse accepted the patient from EMS and not actual arrival time to the hospital`s emergency department. Interview confirmed the time of patient arrival to the ED should have been when the patient entered the facility and the data collected was inaccurate. Interview revealed the facility had designated a hallway in the ED for the EMS to hold the patients awaiting acceptance by the staff. Interview revealed "We didn`t want to put EMS patients in the ED lobby" because "they were priority and we didn`t want to lose them" in the lobby. Interview revealed lack of staff to accept patients from EMS was identified as the main reason for EMS holding patients in the ED.



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Review of EMS Turn Around Times Report dated 06/06/2022 through 06/20/2022 revealed 944 EMS trips. Review revealed 404 trips had an EMS TAT greater than the 30 minute TAT goal (42.8%). Review revealed 26 trips had an EMS TAT greater than 4 hours (2.8%).

Review of EMS Turn Around Times Report dated 01/01/2022 through 06/26/2022 revealed 1801 EMS trips. Review revealed 1249 trips had an EMS TAT greater than the 30 minute TAT goal (69.4%). Review revealed 42 trips had an EMS TAT greater than 4 hours (2.3%).

Interview on 06/23/2022 at 1025 with the ED Director #14 revealed the facility had recently averaged 40-70 inpatients holding in the emergency department while caring for the emergency patients. Interview revealed the facility had staffing challenges which impacted the availability of staff to meet patient needs. Interview revealed the expectation for EMS offloading time was 30 minutes. Interview revealed ED staff were expected to accept the patient within 30 minutes of arrival to the facility. Interview revealed that the facility staff were not "arriving" patients once they presented to the facility which impacted the data collection. Interview revealed that the department had experienced longer wait times and decrease in satisfaction scores due to staffing issues.

Based on policy and procedure review, closed medical record review, and staff interviews, the hospital's nursing staff failed to have an effective nursing service providing oversight to ensure registered nursing staff supervised and evaluated patient care.

The findings included:

1. Based on policy and procedure review, closed medical record reviews, and staff interviews, the nursing staff failed to assess, monitor and evaluate patients who presented to the emergency department (ED) for 3 of 20 sampled ED patients (Patient #7, #20, #4). Patients #7 and #20 had a change in condition that was not assessed by nursing staff and the patient's conditions deteriorated. Patient #7 subsequently died.

~cross refer to 482.23(b)(3) Nursing Standard: Tag A0395

Based on policy and procedure review, closed medical record reviews, and staff interviews, the nursing staff failed to assess, monitor and evaluate patients who presented to the emergency department (ED) for 3 of 20 sampled ED patients (Patient #7, #20, #4). Patients #7 and #20 had a change in condition that was not assessed by nursing staff and the patient's conditions deteriorated. Patient #7 subsequently died.

The findings included:

Review of the facility's "Emergency Department Triage Policy" Last Revised 11/2020 revealed "PURPOSE/SUPPORTING INFORMATION All patients presenting to the Emergency Department shall be evaluated by a Registered Nurse to determine the nature of their presenting complaints, their condition, and their priority for receiving a medical screening exam...PROCEDURE: A. Triage decisions are based on the 5 point Emergency Severity Index (ESI). B. Patients awaiting medical screening exam will be reassessed based on ESI or a minimum every 4 hours..Figure 2-2 ESI Triage Algorithm. v 4 Danger Vital Signs >8 yr ; Respiratory Rate > 20 consider ESI 2 High Risk Situation..."

1. Closed medical record review of Patient #7 revealed a 77 year old female who presented to the facility's emergency department with family on 06/06/2022 at 2031 for a arrival complaint of "Vomiting bile, watery stools, has rectal cancer, weakness, unable to stand x 2 days, loss of app (appetite) last had treatment last week on tue-thurs". Review revealed vital signs at 2043 blood pressure 87/53, pulse 67, respiratory rate 30, oxygenation 90%, Temperature 98.4. Review revealed at 2036 Patient Acuity: 3 (Urgent). Review revealed BP 118/55 at 2106. Patient #7 was placed in the ED waiting room awaiting treatment room assignment. Review revealed next documentation on 06/07/22 at 0200 " Spiritual Care and Assessment and Interventions: Reason for visit: Code Blue (life-saving measures)". Review revealed at 0204 on 06/07/2022 Code Start and Provider at bedside ( 4 hours and 58 minutes) since last assessment. Record review revealed Patient #7 was without a pulse and spontaneous respirations until 0220 on 06/07/2022. Review of ED Nursing note on 06/07/2022 at 0754 (late entry) revealed "This RN alerted to staff assist in intake room. Per triage RN, family notified staff for concern patient worsening. Patient was pulled into intake room to reassess vitals and notify MD. Shortly after, patient lost pulse and CPR (cardiopulmonary resuscitation) was initiated." Record review revealed ED Provider Note on 06/07/22 at 0233 revealed "History of Present Illness: 77 year old female who I am asked to see emergently as she is unresponsive. Upon my arrival to the room the patient has agonal respirations she is cyanotic, a [pulses] quickly lost and CPR (cardio pulmonary resussitation) is begun. She had had multiple rounds of CPR, and I ultimately spoke to family stated she has been here for approximately 6 hours, was increasingly weak, vomiting bile, unable to stand. Also apparently had a fever at home per report. She was told to come to the ED for evaluation. Her daughter noticed that she was unresponsive and not sleeping,she thinks she was unresponsive for approximately 5 minutes and then realized that she was not responding and asked for help. This is when I came to see the patient and initiated treatment..ED Course: ...I have discussed with family and planned for withdrawal of life support given her wishes if she continues to decline... 0401 The patient will be made comfortable anticipate her passing shortly.." Record review revealed Patient #7 pronounced deceased at 0425 on 06/07/2022.

Interview on 06/221/2022 at 1625 with RN (Registered Nurse) #34 revealed she recalled the Code Blue event on 06/07/2022. Interview revealed she arrived at Intake 6 and CPR was in progress. Interview revealed she started to document the events of the Code Blue. Interview revealed the MD (medical doctor) was at bedside when she arrived.

Interview on 06/22/2022 at 1030 with RN #35 revealed she was the triage nurse who assessed Patient #7. Interview revealed she received ESI training during orientation in August 2020. Interview revealed Patient #7 met ESI level 3 due to she was alert and oriented and was not actively vomiting. Interview revealed the EMT (Emergency Medical Technician) completed the vital signs and did not report any abnormal findings to her. Interview revealed Patient #7 did not need a reassessment for 8 hours after triage while waiting for treatment room placement.

Interview on 06/23/2022 at 1510 with EMT (Emergency Medical Technician) #36 revealed she recalled Patient #7 family member asking for help in the waiting room. Interview revealed Patient #7's husband was trying to wake her up and she was not responding. Interview revealed EMT #36 responded to assist and Patient #7 was unresponsive to pain with agonal respirations. Interview revealed she rolled her back to try and get vital sign abnd possibly got a heart rate of 29. Interview further revealed other staff went to get help as she took Patient #7 to Intake 6 where ED MD #37 arrived at same time and Code Blue was called.

Interview on 06/23/2022 at 0920 with ED MD #37 revealed he recalled Patient #7. Interview revealed he was asked to see an unconscious patient. Interview reveled he arrived to Intake 6 at the same time as the nursing staff with the patient. Interview revealed Patient #7 was unresponsive and pulseless upon his initial assessment. Interview revealed the nursing staff told him Patient #7 had a pulse. Interview revealed he never found a pulse on his assessment until after the Code Blue and CPR efforts began.

Interview on 06/23/2022 at 1557 with the ED Educator #13 revealed all nurses receive ESI training during orientation. Interview revealed ESI is a face to face and online class. Interview revealed ESI used to be an annual requirement until 2-3 years ago and currently is only required at hire. Interview revealed when presented with Patient #7 scenario, it was a high risk situation and meets ESI 2 criteria.



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2. Closed medical record review of Patient #20 revealed a 95-year-old female who arrived at the facility on 06/13/2022 via EMS with a chief complaint of weakness. Review of the EMS run sheet revealed Patient #20 arrived at the facility at 2026. Review of the EMS run sheet revealed, " ...Upon arrival EMS was told that no bed were available and that it would be a bit of a wait. After talking to the Dr (doctor) to make sure that the 12-leads (EKG - electrocardiogram) were due to the possibility of the pt having low sodium/potassium crew went to wait. After a few Hr.(hours) crew check on the status of a bed and let the nurse know that the pt was suitable for triage, crew was informed that it would still be a wait. Crew still waiting on a bed after 9 hr (9 hours), crew has informed nurse multiple times that pt meets criteria for triage after speaking to the dr about 12-lead. Crew moved pt into wheelchair and move pt up to intake, transferred care to RN..." Review of the medical record revealed Patient #20 was accepted by facility staff on 06/14/2022 at 0652 (10 hours and 26 minutes after facility arrival). Medical record review revealed the MSE (medical screening exam) started at 0710. Review revealed a CAT Scan of the Head was ordered at 1036 and resulted at 1144. Review of the CAT Scan results dated 1144 revealed, "... Impression: No acute intracranial abnormality..." Review of ED Note signed 06/14/2022 at 1207 revealed, "... Medical Decision Making and Plan: Patient emergency department with generalized weakness. Sodium and potassium are critically low. Started replacing here in the emergency department... 1000am: Patient had mentation change. Was ascus (sic) seen by the nurse. Patient noted to have some right-sided facial droop and does seem to be significantly confused. She is mildly dysarthric (weakness in the muscles used for speech, which often causes slowed or slurred speech)... Considering this acute change CT head ordered. Neurology consult for stat consult to determine whether not this is acute stroke... Neurology felt this likely secondary to be electrolyte abnormalities. Patient's mentation continues to be significantly altered. Hospitalist see has seen the patient and recommends ICU admission to the intensivist..." Review of the medical record revealed Patient #20 was admitted to the Intensive Care Unit on 06/14/2022 at 1602 with a diagnosis of Severe Hypokalemia and Severe Hyponatremia. Medical record review failed to reveal nursing documentation related to the reassessment of Patient #20 or documentation of her change in condition.

Interview on 06/28/2022 at 1415 with Paramedic #17 revealed she recalled the transport of Patient #20 on 06/13/2022. Interview revealed that the charge nurse stated that Patient #20 would have to wait until staff were available. Interview revealed that due to EKG concerns, Paramedic #17 consulted with the physician and was told Patient #20 was fine to wait for triage. Interview revealed at the time of handoff Patient #20 was stable.

Interview on 06/29/2022 at 0907 with RN #3 revealed that he was charge nurse on the night of 06/13/2022. Interview revealed RN #3 did not recall Patient #20. Interview revealed that staff were expected to assess their patients per policy and document what they perform.

Interview on 06/23/2022 at 1025 with the ED Director #14 revealed the facility had staffing challenges which impacted the availability of staff to meet patient needs. Interview revealed the expectation of nursing staff was to follow the facility policy regarding assessments and reassessments.

3. Closed medical record review of Patient #4 revealed a 4-year-old male who arrived at the ED on 06/13/2022 at 2106 via private vehicle. Record review revealed the chief complaint was a laceration to the back of the head. Medical record review revealed Patient #4 was triaged at 2107 and vital signs performed at 2120 were as follows: Temperature - 98.2F, Heart Rate - 155, Oxygen Saturation - 98%, Respirations - 36, Weight - 39 lbs., 3.2oz, and Blood Pressure - (Unable to obtain d/t (due to) crying screaming). A pain assessment was not documented. Medical record review revealed Patient #4 was placed in the lobby with his parents to wait. Record review revealed the Medical Screening Exam (MSE) was performed on 06/14/2022 at 0734. Additional vital signs were obtained at 0923: Temperature - 98.4F, Heart Rate - 132, Oxygen Saturation - 100%, Respirations - 20, Pain - denies (12 hours and 3 minutes after the first vital sign assessment). Medical record review revealed Patient #4 was discharged home on 06/14/2022 at 0924 with his parents. Medical record review failed to reveal the reassessment of the patient on a four-hour interval before his MSE was performed (0100, 0500 missing reassessments).

Interview on 06/22/2022 at 1415 with RN #32 revealed he recalled caring for Patient #4 on the morning of 06/14/2022. Interview revealed the family had been waiting all night, so he got supplies set up for the provider and performed a set of discharge vitals after the staples were done on the head laceration. Interview revealed that vital signs were to be performed on a four-hour interval for patients awaiting an MSE.

Interview on 06/23/2022 at 0930 with RN #33 revealed she recalled performing the triage on Patient #4. Interview revealed that the protocol for monitoring in the waiting room was every four hours. Interview revealed that depending on staffing and patient volumes, it was challenging to reassess and monitor patients waiting for their MSE every four hours.

Interview on 06/23/2022 at 1025 with the ED Director #14 revealed the expectation of nursing staff to follow the facility policy regarding assessments and reassessments. Interview revealed nursing staff should have performed vital signs at minimum every 4 hours on all patients waiting to have their MSE.

Based on review of policy, Medical record review and staff, physician and other personnel interviews, the facility failed to coordinate a safe discharge by failing to ensure post discharge needs could be met for 1 of 2 patients discharged to jail (#16).

The findings included:

Review on 06/2722 of policy titled "Discharge Planning" with revision date of 10/2015, revealed "PURPOSE/SUPPORTING INFORMATION: It is the philosophy of (named hospital) that all admitted inpatients require a discharge plan to reduce the risk of adverse health consequences post-discharge. Discharge Planning is an interdisciplinary process that is started upon admission with the initial assessment of the patient performed by the physician and the staff nurse as documented in the History and Physical and the Initial Assessment. The plan is developed based upon the initial and ongoing assessment of patient/family needs in collaboration with the patient, family, and significant others and input from any health provider involved directly in the care of the patient."

Review of History and Physical dated 05/31/2022 at 2052 revealed Patient #16, a 43 year old female was received to named hospital via air transport for "MVC (Motor Vehicle Collision) having significant pain in her lower extremities; L>R (Left more than right) Admits to drinking tonight...On methadone (synthetic analgesic drug) ...presents as a trauma I; unclear mechanism or if self extricated or ejected--pt found in a ditch. Injury list: 1. Comminuted (bones broken in at least 2 places) bilateral (both) tib/fib (tibia and fibula--both lower leg bones) fracture involving ankle...." Review revealed Patient #16's hospital stay included "Bilateral ankle wash out/splinting of left ankle/right ankle external fixation place" on 06/01/22. On 06/08/2022, Patient #16 had ORIF (open reduction and internal fixator--surgical placement of hardware stabilize and heal broken bones) left ankle. Five days later on 06/13/2022, Patient #16 had removal of external fixator of right ankle. Review revealed Physical Therapy #20's evaluation of Patient #16 on 06/14/2022 at 1544 revealed "Patient complaining of increased pain overall since surgery. NWBing (Non-weight bearing) on BLE (Bilateral lower extremity) after surgery with no change in status since ex fix (external fixator) removal...Stand by assist with verbal cues for safety, and sequencing with initial transfer to BSC (bedside commode) ...Recommendation: SNF (skilled nursing care). Activity limited by fatigue." Review of evaluation by OT (Occupational Therapy) note written on 06/13/2022 at 0842 revealed "...OT Recommendations: SNF. Difficult discharge do (sic) to multiple limiting factors--methadone use, living with father, NWB BLE/wheelchair, no insurance." Review of Discharge Summary dated 06/16/2022 at 1636 written by MD #23 revealed "Patient is medically stable for discharge to correctional facility." "Activity: non weight bearing on bilateral lower extremity. Brace: Wear splint, remove daily for bathing, wound care, and Physical Therapy range of motion exercises. Range of Motion: No ROM. Can perform slide transfers. Elevate your bilateral lower extremity above your heart when at rest to help reduce swelling. OK to shower daily. No soaking in a bath or pool until cleared by the physician. Keep dressings and/or splints clean and dry. Wound care: Leave post op bandaid dressing (Aquacel-foam dressing) in place for 7 days (until 6/15) then replace with new Aquacel or start daily dry gauze dressing changes. If it becomes more than 75% saturated before then, remove it and start twice daily dry gauze dressing changes at that time. May shower with Aquacel in place as long as the edges maintain a good seal. After Aquacel removed---Wash hands before and after all dressing changes. Wash around incision/wound with damp cloth and soap once a day, dry thoroughly! Dressing changes with dry gauze and tape daily. Please remove staples from 2 weeks after surgery (LEFT ankle--06/22, RIGHT ankle-06/27). If there are any concerns with the incisions, please take a picture and email to (surgeon).... Follow up with your primary care physician to notify them of your admission. Follow up with (orthopedic surgeon) in 2 weeks (06/24/2022) at (local office). Call to schedule appointment ASAP." Review of CM #24 note dated 06/16/2022 at 0944 revealed "LCSW messaged team who stated patient was ready for d/c (discharge). LCSW contacted Special Police to inform them of this information. Awaiting transport time to update Bedside RN and team. CM/LCSW will continue to follow for all discharge needs. (This note will not be released to the patient for the following reason: Patient flight risk prior to d/c to jail)." Review of discharge instructions dated 06/16/22 at 1040 by RN #22 revealed "Patient received a copy of the After Visit Summary." Review revealed no evidence of report called to jail prior to discharge.

Interview on 06/27/2022 at 1655 with RN #22 who discharged Patient #16 revealed the nurse remembered the patient. Interview revealed Patient #16 signed discharge papers before the police arrived, adding Patient #16 was not aware of the discharge to jail. Interview revealed local police arrived about 45 minutes before Patient #16 was discharged. Interview revealed Patient #16 had orders for NWB on bilateral legs due to surgery. Interview revealed no documentation of teaching dressing changes to patient.

Interview on 06/29/2022 at 1145 with PT #20 (Physical Therapist) revealed Patient #16 was discharged to jail on 06/16/2022. Interview revealed Patient #16 was seen and evaluated by Physical Therapy on 06/07/2022 and 06/14/2022. Interview revealed Patient #16 remained NWB throughout hospital stay and at discharge. Interview revealed Patient #16 used the slide board to move from one location to another, such as bed to chair. Interview revealed Patient #16's discharge plan and recommendation were discharging to skilled nursing facility due to patient needs.

Interview on 06/28/2022 at 1335 with MD #23 revealed Patient #16 was discharged with NWB status of bilateral legs due to surgery and trauma. Interview revealed discharge plans are coordinated with team. Interview revealed discharge plans depend on case managers to coordinate discharge plan. Interview of MD #23 revealed Patient #16 was medically cleared for discharge to a correctional facility.

Interview on 06/28/2022 at 1125 with CM #24 revealed Patient #16 was assigned as a discharge from another coworker. CM #24 wrote a note in the chart about discharge. Interview revealed Patient #16 had obstacles and could not qualify for skilled nursing due to financial reasons. Patient #16 could not qualify for the acute rehab due to the intensity and 3-hour requirement of therapy daily. Interview revealed Patient #16 was scheduled to be discharged to home with DME (durable medical equipment) and handicapped accessible with a caregiver. Interview revealed Patient #16 was not allowed to carry any items except foot boot to the jail upon discharge. Interview revealed no report was called to the facility regarding patient's medical needs.

Interview on 06/29/2022 at 1344 with Supervisor #25 (jail supervisor) revealed Patient #16 was transported by local police to local jail due to pending charges. Interview revealed "as soon as (Patient #16) arrived, we started the process to move her due to her non weight bearing status. We couldn't handle her." Interview revealed Patient #16 was transported via a truck to another facility 4 days later. Interview revealed Patient #16 required 5 men to lift patient into the truck indicating the truck was chosen for comfort instead of the large passenger van. Interview revealed Patient #16 would not have been comfortable for a 2-hour ride without legs elevated. Interview revealed Patient #16 required lifting by the staff members due to non-weight bearing status. "We don't have nurses to care for patients who require lots of nursing care." Interview revealed no report was called to the facility identifying medical needs of Patient #16.

Based on observation, policy review, staffing plan review, staffing report review, patient volumes review, medical record review,EMS (Emergency Medical Services) Patient Care reports and staff interview, EMS, physician and staff interviews, the facility failed to meet the emergency needs of patients.

The findings included:

1. Based on hospital policy review, EMS (Emergency Medical Services) Patient Care Reports, EMS staff and physician interviews, the hospital failed to ensure an organized and effective emergency services by failing to ensure emergency services staff provided an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 5 of 20 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patients #31, #32, #28, #29, #30 ).

~Cross refer to 482.55(a) : Emergency Services Standard Tag A1101

2. Based on observation, policy review, staffing plan review, staffing report review, patient volumes review, medical record review, and staff interview, the facility failed to maintain adequate numbers of qualified personnel available to meet the needs of incoming patients with emergent conditions in 9 of 10 patients who arrived by EMS (Patient #8, #20,# 24,# 6 #31, #32, # 28,# 29,# 30).

~Cross refer to 482.55(b)(2) : Emergency Services Standard Tag A1112

Based on hospital policy review, EMS (Emergency Medical Services) Patient Care Reports, EMS personnel, emergency department staff and physician interviews, the hospital failed to ensure an organized and effective emergency services by failing to ensure emergency services staff provided an appropriate medical screening examination to determine whether or not an emergency medical condition existed for 5 of 20 sampled patients that presented to the hospital's DED (dedicated emergency department) and requested medical treatment (Patients # 31, #32,#28, #29, #30 ).

The findings included:

Review of the "EMTALA (Emergency Medical Treatment and Labor Act) - Medical Screening" effective 02/2021, revealed " PROCEDURE: A. When a Medical Screening Examination Is Required: 1. A person presents on their own. If an individual arrives at the hospital and is not technically in the emergency department, but on Hospital Property or Premises (as defined under this policy) and requests emergency care, he or she must receive a medical screening examination within the capabilities of the facility. 2. A person presents in a ground or air ambulance owned and operated by the hospital. 3. A person present in a Non hospital owned ambulance ... a. An individual in a non-hospital owned ambulance that is on hospital property is considered to have come to the hospital's emergency department ... C. Medical Screening Examination: 1. A medical screening examination will be provided when an individual comes by him/herself or with another person to the emergency department of the hospital, and a request is made on the individual's behalf for a medical examination or treatment.

1. Closed medical record review of Patient # 31 revealed a 92 year old female who presented to the facility's emergency department via EMS on 05/31/2022 at 1722 for a chief complaint of syncope. Review of the EMS patient care report revealed Patient #31 was alert and oriented with a BP of 132/89, pulse 81, respiratory rate 18. Review of EMS patient care report revealed "EMS arrives at receiving. One EMS crew member went into receiving to register patient. Triage notified EMS as long as patient had mask on patient could come inside to stage in hallway. With mask in place on patient, patient was transferred into receiving. EMS asked to stage in hallway until room became available. During wait time patient was assisted to bathroom. While waiting for room patient slept on stretcher. After extensive wait time, EMS asked triage if patient could be triaged due to patients stability and that there were ALS (advanced life support) interventions at that time. Triage nurse declined sitting she did not want patient to sit in the lobby with family due to syncopal episode as patient's chief complaint, Charge nurse was consulted and she advised patient could not be triaged for same. EMS notified the wait time could extend another 9 hours possibly. Patient and family were advised of further extended wait times. Patient and patient's family decided to take patient to another facility for treatment. Another set of vital signs were obtained, refusal..explained to them... EMS assisted patient transferring from wheelchair to front seat of POV (privately owned vehicle)." Patient #31 signed an EMS Refusal releasing them from EMS care. Review revealed Patient left EMS care at 2110. Review revealed patient care was never transferred to emergency department personnel and Patient #31 left the facility with family after waiting 3 hours and 48 minutes.

Interview on 06/29/2022 at 1015 with Paramedic #38 revealed she was the EMS personnel who transported Patient #31 to the emergency department. Interview revealed the patient's vital signs were stable and she was capable to sit in triage with family to prevent in a delay in triage. Interview revealed no nursing staff triaged the patient while waiting. Interview revealed the emergency department staff say "she's your patient, she's in your care until we take report". Interview revealed the family was tired of waiting and wanted to take the patient to another hospital. Interview revealed EMS personnel made the charge nurse aware and the hospital staff did not speak to the patient's prior to departure. EMS staff assisted the patient to family's car.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

Interview on 06/24/2022 at 1250 with the previous Emergency Department Administrative Coordinator revealed when a patient voices a desire to leave the emergency department without completing treatment or a medical screening exam, a written refusal is attempted and risks and benefits are explained to the patient. Interview revealed the charge nurse is made aware and notifies the physician. Interview revealed patients waiting with EMS staff for triage and room placement should also have a written refusal by emergency department staff prior to leaving the facility.

2. Closed medical record review of Patient #32 revealed a 67 year old female who presented to the facility's emergency department on 06/09/2022 at 1408 via EMS for a chief complaint of chest pain. Review of EMS patient care report revealed at 1408 "....Pt (patient) registered and report given to the triage nurse. No significant changes in pt condition while waiting for bed..." Review revealed at 1530 BP 102/57, pulse 72, oxygenation 94% and respiratory rate 12. Further review revealed at 1620 "Pt began complaining of increased r (right) sided chest pain radiating to her r arm. Nitroglycerin (medication used to treat chest pain), .4 MG via SL (sublingual) given (by named EMS Staff member)... Authorization:via Protocol. Pt response: Improved..." EMS report review revealed at 1908 "Pt stating she would like to leave ER AMA (against medical advise). Pt advised of possible consequences if leaving before being seen by a doctor. Pt verbalized understanding of possible consequences and signature obtained.." Record review revealed Patient #32 signed EMS refusal (5 hours after arrival). Review of facilty emergency department medical record revealed Patient #32 disposition set at 2043 "LWBS (left without being seen) before triage" and discharged at 2044.

Interview on 06/29/2022 at 1215 with Paramedic # 39 revealed he recalled Patient # 32. Interview revealed EMS staff had to treat the patient due to the complaint of chest pain. Interview revealed they have treatment protocols. Interview revealed the patient was tired of waiting. Interview revealed the ED staff never attempt to get a refusal of treatment from a patient waiting with EMS staff. Interview revealed he did notify ED staff Patient #32 was wanting to leave but they did nothing because Patient #32 was "still under the care of EMS staff in the hallway".

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

Interview on 06/24/2011 at 1250 with the previous Emergency Department Administrative Coordinator revealed when a patient voices a desire to leave the emergency department without completing treatment or a medical screening exam, a written refusal is attempted and risks and benefits are explained to the patient. Interview revealed the charge nurse is made aware and notifies the the physician. Interview revealed patients waiting with EMS staff for triage and room placement should also have a written refusal by emergency department staff prior to leaving the facility.



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3. Closed medical record review revealed Patient #28 was a 76-year-old male brought to the emergency department (ED) by emergency medical service (EMS) on 05/23/2022 with a complaint of vomiting. Review of the EMS run report revealed EMS arrived in the ED with Patient #28 at 2052. Review of the ED Timeline revealed the hospital documented Patient #28's arrival in the ED as 0139 (4 hours 47 minutes after EMS arrived with the patient). Review revealed the ED disposition was set to "LWBS before Triage" at 0142 (4 hours 50 minutes after EMS arrived with the patient). Review of the medical record revealed no MSE and no documentation of risk and benefits were discussed with Patient #28 by hospital staff prior to him leaving the ED.

Telephone interview on 06/28/2022 at 1359 with Paramedic #28 revealed he transported Patient #28 to the ED. Interview revealed when they arrived in the ED there were already 3 or 4 other EMS with stretchers with patients waiting to be seen. Interview revealed Paramedic #28 checked in with the triage nurse. Interview revealed a hospital staff member came to the stretcher and asked Patient #28 questions and then put a wrist band on the patient. Interview revealed after five hours waiting and not being see or evaluated, Patient #28 decided she was going to leave. Interview revealed Paramedic #28 notified the charge nurse of Patient #28 wanting to leave. Interview revealed the charge nurse notified Paramedic #28 the patient (Patient #28) did not need to sign anything for the hospital because they were not a patient of the hospital. Interview revealed Paramedic #28 had Patient #28 sign an EMS Refusal releasing them from EMS care. Interview revealed the hospital front desk staff called a taxi for Patient #28 to leave.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

Telephone interview on 06/29/2022 at 0904 with RN #27 revealed she vaguely remembered Patient #28. Interview revealed EMS brings the patients in, gives report to the charge nurse/coordinator and depending on the situation and if a bed is available, they either take the patient to a room or they stay with the patient until a room becomes available. Interview revealed RN #27 did not remember and probably did not talk with Patient #28 about risk of leaving without being seen nor the benefit of staying and being evaluated by a provider when a bed was available. RN #27 stated it is the nursing staff and/or the hospital staff responsibility to talk with the patient to explain they are trying to get a spot for the patient to be seen by the provider.

4. Closed medical record review revealed Patient #29 was a 53-year-old male brought to the emergency department (ED) by emergency medical service (EMS) on 06/13/2022 with a complaint of AMS (altered mental status) EKG (electrocardiogram-recording of electrical signals in the heart) showing RBB (right bundle branch block). Review of the EMS run report revealed EMS arrived in the ED with Patient #29 at 1518. Review of the ED Timeline revealed the hospital never documented Patient #29's arrival in the ED. Review revealed Patient #28 had blood collected for lab test at 1527 by "EMS Collector". Review revealed the ED disposition was set to "LWBS before Triage" on 06/14/2022 at 0101 (10 hours after EMS arrived with the patient). Review of the medical record revealed no MSE and no documentation of risk and benefits were discussed with Patient #29 by hospital staff prior to him leaving the ED.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

Telephone interview on 06/29/2022 at 1103 with Paramedic #29 revealed he transported Patient #29 to the ED. Interview revealed Patient #29 had AMS and was started on IVF (intravenous fluids). Interview revealed Paramedic #29 arrived in the hospital on 06/13/2022 at 1518. Interview revealed there were no beds and EMS had to stay with and monitor Patient #29. Interview revealed Paramedic #29 monitored Patient #29 from arrival time in the hospital of 1518 until he signed off shift at 1916 when Paramedic #29 gave report to the oncoming EMS crew.

Telephone interview on 06/29/2022 at 1406 with RN #26 (identified by the hospital as the charge nurse on 05/23/2022) revealed she did not remember Patient #29.

5. Closed medical record review revealed Patient #30 was a 76-year-old female brought to the emergency department (ED) by emergency medical service (EMS) on 05/23/2022 at 2049 with a complaint of vomiting. Review of the EMS run report revealed EMS arrived in the ED with Patient #30 at 2052. Review of the ED Timeline revealed the hospital documented Patient #30's arrival in the ED as 0139 (4 hours 47 minutes after EMS arrived with the patient). Review revealed the ED disposition was set to "LWBS before Triage" at 0142 (4 hours 50 minutes). Review of the medical record revealed no MSE and no documentation of risk and benefits were discussed with Patient #30 by hospital staff prior to her leaving the ED.

Telephone interview on 06/28/2022 at 1359 with Paramedic #28 revealed he transported Patient #30 to the ED. Interview revealed when they arrived in the ED there were already 3 or 4 other EMS with stretchers with patients waiting to be seen. Interview revealed Paramedic #28 checked in with the triage nurse. Interview revealed a hospital staff member came to the stretcher and asked Patient #30 questions and then put a wrist band on the patient. Interview revealed after five hours waiting and not being seen or evaluated, Patient #30 decided she was going to leave. Interview revealed Paramedic #28 notified the charge nurse of Patient #30 wanting to leave. Interview revealed the charge nurse notified Paramedic #28 the patient (Patient #30) did not need to sign anything for the hospital because they were not a patient of the hospital. Interview revealed Paramedic #28 had Patient #30 sign an EMS Refusal releasing them from EMS care. Interview revealed the hospital front desk staff called a taxi for Patient #30 to leave.

Telephone interview on 06/29/2022 at 0904 with RN #27 that documented Patient #30's arrival to the ED and disposition on the ED Timeline revealed she vaguely remembered Patient #30. Interview revealed EMS brings the patients in, gives report to the charge nurse/coordinator and depending on the situation and if a bed is available, they either take the patient to a room or they stay with the patient until a room becomes available. Interview revealed RN #27 did not remember and probably did not talk with Patient #30 about risk of leaving without being seen nor the benefit of staying and being evaluated by a provider when a bed was available. RN #27 stated it is the nursing staff and/or the hospital staff responsibility to talk with the patient to explain they are trying to get a spot for the patient to be seen by the provider.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

Based on observation, policy review, staffing plan review, staffing report review, patient volumes review, medical record review, and staff interview, the facility failed to maintain adequate numbers of qualified personnel available to meet the needs of incoming patients with emergent conditions in 9 of 10 patients who arrived by EMS (Patient #8, #20,# 24,# 6 #31, #32, # 28,# 29,# 30).

The findings included:

Observation on 06/21/2022 at 1155 during facility tour revealed the Emergency Department (ED) had 108 beds, up to 200 spaces when hallway beds were included. Observation revealed the ED currently had 138 patients in the unit. 64 patients were inpatient status and waiting for bed placement. Observation revealed the current number of nursing staff was 13.

Observation on 06/29/2022 at 1330 during facility tour revealed the ED had 111 patients in the unit. 53 patients were inpatient status and waiting for bed placement. Observation revealed the current number of nursing staff was 20.

Review of the facility policy, "Patient Bill of Rights and Responsibilities" effective 01/2020, revealed, " ...The patient has the right to expect emergency procedures to be implemented without unnecessary delay ..."

Review of the facility's "Emergency Department Triage Policy" last revised 11/2020, revealed, "PURPOSE/SUPPORTING INFORMATION All patients presenting to the Emergency Department shall be evaluated by a Registered Nurse to determine the nature of their presenting complaints, their condition, and their priority for receiving a medical screening exam..."

Review of the ED staffing plan revealed the staffing pattern for 108 bedded patients resulted in 25 RNs and 14 Paramedic/ ED Techs.

1. Open medical record review of Patient #8 revealed a 53-year-old male patient who arrived at the facility on 06/20/2022 via EMS (emergency medical services) with a chief complaint of agitation. Review of the EMS run sheet revealed Patient #8's facility arrival was at 1940. Review of the EMS run sheet revealed, " ... 1942 - Medical Consult: (named paramedic) consulted with (named ED physician) via In Person. PT (patient) increasingly agitated and confused. Additional sedation needed ... 1954: Heart Rate - 96, Blood Pressure - 169/97, Oxygen Saturation - 100%, Respirations - 28 ... 2000: Lorazepam (Sedative, commonly used for seizures or anxiety) 2 MG (milligram) via IV (intravenous) Push... Pt. response: unchanged... Haloperidol (Antipsychotic, commonly used for mental/mood disorders) 15 MG via IV Push... Pt response: unchanged... 2010: Heart Rate - 102, Blood Pressure - 172/100, Oxygen Saturation - 100%, Respirations - 30 ... 2030: Ketamine (Anesthetic, commonly used for sedation), 400 MG via IM (intramuscular)... Pt response: improved... 2035: Heart Rate - 120, Blood Pressure - 181/102, Oxygen Saturation - 97%, Respirations - 26 ... 2040: A pt care report was given and care of the pt was transferred to the receiving RN staff ..." Review of the EMS run sheet revealed that Paramedic #15 administered the Lorazepam, Haloperidol, and Ketamine medications per the verbal order of MD# 11 while waiting in the ED hallway. Review of the medical record revealed Patient #8 was accepted by the facility ED staff at 2036 (56 minutes after facility arrival). Medical record review revealed the MSE (medical screening exam) started at 2039 and Patient #8 was subsequently sedated and intubated at 2207. Review of the medical record revealed Patient #8 was admitted to the Intensive Care Unit on 06/20/2022 at 2316 with a diagnosis of Acute Toxic Metabolic Encephalopathy. Medical record review revealed qualified personnel was not available to meet the emergent needs of Patient #8 upon facility arrival at 1940 for 56 minutes.

Review of the Staffing Report for the ED cost center for 06/20/2022 at 2000 revealed: 1 RN - ED, 4 RNs - BHU (behavioral health), 10.75 RNs - IP (inpatient). Review revealed inpatient nurses cared for ED patients in their assignments.

Review of the EMR (electronic medical record) Patient Volumes Report for 06/20/2022 at 2000 revealed: ED Patients - 60, Behavioral Health - 28, Inpatient (Patients admitted to the facility but housed within the emergency department) total - 63. Review revealed a total of 151 patients being cared for within the emergency department.

Interview on 06/22/2022 at 1318 with Paramedic #15 revealed that he provided care for Patient #8 on 06/20/2022. Interview revealed Patient #8 was agitated and did not follow verbal commands. Interview revealed that when the EMS team arrived at the facility they were advised to wait in the hallway until staff were available to receive handoff report. Interview revealed Paramedic #3 consulted with MD #2 due to Patient #8's increased agitation in the hallway. Interview revealed MD #2 gave Paramedic #3 verbal orders for sedation medication. Interview revealed the medications were administered in the hallway and shortly afterwards Patient #8 was placed into a room. Interview revealed the facility staff took over care of Patient #8 and began his triage and medical screening exam after the administration of the medication in the hallway. Interview revealed that the availability of ED staff to meet the needs of patients upon facility arrival varied heavily based on facility staffing.

Interview on 06/23/2022 at 0947 with RN #3 revealed he was the charge nurse on the night of 06/20/2022. Interview revealed RN #3 was notified by EMS that Patient #8 required medication to decrease his agitation. Interview revealed EMS requested the use of a patient room instead of remaining in the hallway while waiting to handoff to facility staff. RN #3 revealed the nursing staff did not assume care of the patient until after report was received from EMS, which varied from minutes to hours after facility arrival.

Interview request for the RN assigned to Patient #8 on the night of 06/20/2022 revealed she was unavailable for interview.

Interview on 06/23/2022 at 1025 with the ED Director #14 revealed the facility had recently averaged 40-70 inpatients holding in the emergency department while caring for the emergency patients. Interview revealed the facility had staffing challenges which impacted the availability of staff to meet patient needs. Interview revealed the expectation for EMS offloading time was 30 minutes. Interview revealed ED staff were expected to accept the patient within 30 minutes of arrival to the facility. Interview revealed that the department had experienced longer wait times and decrease in satisfaction scores due to staffing issues.

Interview on 06/24/2022 at 1230 with the Nurse Manager #16 revealed that the facility had created roles to assist with offloading the patients from EMS staff, but it relied on staffing availability. Interview revealed that staffing the ED with qualified professionals like RNs, Paramedics, and ED Techs to meet the patient needs was a challenge and had impacted the level of care that patients received. Interview revealed that ED staff commonly took assignments with inpatients or behavioral health patients while caring for emergency patients.

Interview on 06/23/2022 at 0852 with MD #11 revealed he was the ED provider for Patient #8 on 06/20/2022. Interview revealed MD #11 recalled the discussion with EMS about Patient #8's agitation and the verbal orders for medication. Interview revealed that providers gave EMS orders to carry out in the hallway before the patients were triaged or assessed by the facility staff. Interview revealed that due to the patient volume and staff constraints, the providers use whatever resources they have available like EMS paramedics giving medications in the hallway.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement. Interview revealed the providers gave EMS staff orders for hallway patients prior to triage and room placement.

2. Closed medical record review of Patient #20 revealed a 95-year-old female who arrived at the facility on 06/13/2022 via EMS with a chief complaint of weakness. Review of the EMS run sheet revealed Patient #20 arrived at the facility at 2026. Review of the EMS run sheet revealed, " ...Upon arrival EMS was told that no bed were available and that it would be a bit of a wait. After talking to the Dr (doctor) to make sure that the 12-leads (EKG - electrocardiogram) were due to the possibility of the pt having low sodium/potassium crew went to wait. After a few Hr.(hours) crew check on the status of a bed and let the nurse know that the pt was suitable for triage, crew was informed that it would still be a wait. Crew still waiting on a bed after 9 hr (9 hours), crew has informed nurse multiple times that pt meets criteria for triage after speaking to the dr about 12-lead. Crew moved pt into wheelchair and move pt up to intake, transferred care to RN..." Review of the medical record revealed Patient #20 was accepted by facility ED staff on 06/14/2022 at 0652 (10 hours and 26 minutes after facility arrival). Medical record review revealed the MSE (medical screening exam) started at 0710 and the patient subsequently developed right sided facial droop and went to CAT Scan. Review of the medical record revealed Patient #20 was admitted to the Intensive Care Unit on 06/14/2022 at 1602 with a diagnosis of Severe Hypokalemia and Severe Hyponatremia. Medical record review revealed qualified personnel was not available to meet the emergent needs of Patient #20 upon facility arrival at 2026 for 10 hours and 26 minutes.

Review of the Staffing Report for the ED cost center for 06/14/2022 at 0000 revealed: 9 RN - ED, 3.5 RNs - BHU (behavioral health), 5 RNs - IP (inpatient). Review revealed ED RNs cared for inpatients within their assignments.

Review of the EMR (electronic medical record) Patient Volumes Report for 06/14/2022 at 0000 revealed: ED Patients - 96, Behavioral Health - 45, Inpatient total - 59. Review revealed a total of 200 patients being cared for within the emergency department.

Interview on 06/28/2022 at 1415 with Paramedic #17 revealed she recalled the transport of Patient #20 on 06/13/2022. Interview revealed that the charge nurse stated that Patient #20 would have to wait until staff were available. Interview revealed that due to EKG concerns, Paramedic #17 consulted with the physician and was told Patient #20 was fine to wait for triage. Interview revealed the facility had a policy that EMS was not allowed to leave their patient until the facility accepted them for triage. Interview revealed the EMS staff waited 10 hours with Patient #20 without a triage or assessment from the facility staff. Interview revealed the facility offloading time was customarily one to six hours.

Interview on 06/29/2022 at 0907 with RN #3 revealed that he was charge nurse on the night of 06/13/2022. Interview revealed RN #3 did not recall Patient #20. Interview revealed that at 1900 when he arrived at work, there were 164 patients in the department and 13 ambulances awaiting offloading. Interview revealed 75 of the 164 patients were awaiting inpatient beds. The remaining 89 patients were behavioral health and emergency room patients. Interview revealed that on the night of 06/13/2022, one of the travel nurses refused their assignment which increased the nurse to patient ratio. Interview revealed that the midshift nursing staff left at 2200, 2300, and 0100. By 0100, there were 161 patients with 70 inpatients waiting for hospital placement and 10 EMS holding hallway patients while waiting for offloading. Interview revealed RN #3 had 6 overnight nurses to care for the remaining 91 emergency room and behavioral health overflow patients. Interview revealed that staffing had been short, and it is challenging to care for patients without adequate staff.

Interview on 06/23/2022 at 1025 with the ED Director #14 revealed the facility had recently averaged 40-70 inpatients holding in the emergency department while caring for the emergency patients. Interview revealed the facility had staffing challenges which impacted the availability of staff to meet patient needs. Interview revealed the expectation for EMS offloading time was 30 minutes. Interview revealed ED staff were expected to accept the patient within 30 minutes of arrival to the facility. Interview revealed that the department had experienced longer wait times and decrease in satisfaction scores due to staffing issues.

Interview on 06/24/2022 at 1230 with the Nurse Manager #16 revealed that the facility had created roles to assist with offloading the EMS staff, but it relied on staffing availability. Interview revealed that staffing the ED with qualified professionals like RNs, Paramedics, and ED Techs to meet the patient needs was a challenge and had impacted the level of care that patients received. Interview revealed that ED staff commonly took assignments with inpatients or behavioral health patients while caring for emergency patients.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

3. Closed medical record review of Patient #24 revealed a 21-year-old female who arrived at the facility on 06/25/2022 with a chief complaint of Seizures/Psychiatric. Review of the EMS run sheet revealed the patient arrived at the facility at 1624. Review of the EMS run sheet revealed, " ...Pt was registered at time arrived at ED. Crew spoke with Intake RN, (named). (Named RN) stated nothing available at this time. Crew explained that IVC (involuntary commitment) paperwork was enroute to ED. (Named RN) then stated to let him know when it arrives because at that time, he can place her in psych (psychiatric) area. Crew notified (Named RN) at time that (Named Police Department) arrived with IVC papers. (Named RN) was walking and threw his arms up and stated I don't have anywhere to put her. I asked for (facility police). (Named RN) stated they are busy with other things in the ED. I once again spoke with (Named RN) when he was at the Intake Room, he then stated very rudely that he does not have anywhere to put the IVC. Crew then placed PT in a wheelchair and wheeled her to hall next to Intake RN (Named RN) and asked him where he would like the paperwork. (Named RN) then stated he is not signing anything, I (named paramedic), then asked him where he wanted the paperwork because he didn't have to sign. Pt left beside Intake RN with (Named Police Department) and (Facility Police)." Review of the medical record revealed Patient #24 was accepted by facility staff on 06/25/2022 at 1736 (1 hour and 12 minutes after facility arrival). Medical record review revealed the MSE (medical screening exam) started at 1745. Review of the medical record revealed Patient #24 was discharged home from the facility on 06/26/2022 at 1032 with a diagnosis of Aggressive Behavior, Suicidal Ideation, and Substance Abuse. Medical record review revealed qualified personnel were not available to meet the emergent needs of Patient #24 upon facility arrival at 1624 for 1 hour and 12 minutes.

Review of the Staffing Report for the ED cost center for 06/25/2022 at 1700 revealed: 4.75 RNs - ED, 3 RNs - BHU (behavioral health), 9 RNs - IP (inpatient). Review revealed Inpatient RNs cared for ED patients within their assignments.

Review of the EMR (electronic medical record) Patient Volumes Report for 06/25/2022 at 1700 revealed: ED Patients - 53, Behavioral Health - 19, Inpatient total - 60. Review revealed a total of 132 patients being cared for within the emergency department.

Interview on 06/28/2022 at 1601 with Paramedic #18 revealed she recalled the transport of Patient #24. Interview revealed that upon arrival EMS approached the charge nurse to give them a quick report and inform them that Patient #24 was going to be involuntarily committed. Interview revealed that later on the charge nurse refused handoff of the patient and stated there was nowhere to put the patient. Interview revealed that the facility staff were not available to accept the care of the incoming EMS patients for several hours at peak hours. Interview revealed Paramedic #18 has waited 8 hours to perform a handoff to facility staff.

Interview on 06/28/2022 at 1642 with RN #19 revealed he did not fully recall Patient #24. Interview revealed that recently staffing and bed placement has been challenging. Interview revealed that on the night of 06/25/2022 the patient volume was high with high acuity. Interview revealed that a bed space was eventually secured in the behavioral health area for Patient #24.

Interview on 06/23/2022 at 1025 with the ED Director #14 revealed the facility had recently averaged 40-70 inpatients holding in the emergency department while caring for the emergency patients. Interview revealed the facility had staffing challenges which impacted the availability of staff to meet patient needs. Interview revealed the expectation for EMS offloading time was 30 minutes. Interview revealed ED staff were expected to accept the patient within 30 minutes of arrival to the facility. Interview revealed that the department had experienced longer wait times and decrease in satisfaction scores due to staffing issues.

Interview 06/24/2022 at 1230 with the Nurse Manager #16 revealed that the facility had created roles to assist with offloading the EMS staff, but it relied on staffing availability. Interview revealed that staffing the ED with qualified professionals like RNs, Paramedics, and ED Techs to meet the patient needs was a challenge and had impacted the level of care that patients received. Interview revealed that ED staff commonly took assignments with inpatients or behavioral health patients while caring for emergency patients.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.



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4. A closed medical record review of Patient #6 revealed an 83-year-old female who arrived at the facility on 06/13/2022 via EMS (emergency medical services) with a chief complaint of increased confusion. A review of the EMS run sheet revealed Patient #6 arrived at the facility at 0416. The review of the EMS run sheet revealed, "...Pt (patient) transported to named facility ED (emergency department) hallway, report given to Named RN (Registered Nurse) charge nurse who requested a doctor to check pt out for triage purposes. Dr (doctor) came to stretcher to assess pt and states she does not meet stroke criteria and states pt will have to wait for room and orders for CT (computerized tomography) and labs. ...Crew wants to make the ED aware that pt has new onset immobility in lower ext (extremities) and daughter states she is not behaving normally. ER (emergency room) doctor was not concerned ..." A review of the medical record revealed the facility documented Patient #6 arrived on 06/13/2022 at 0851 (4 hours and 35 minutes after the patient's actual arrival). The medical record review revealed the MSE (medical screening exam) started at 0902 and the patient was subsequently admitted on 06/13/2022 at 2016 with a diagnosis of AMS (altered mental status). The medical record review revealed qualified personnel was not available to meet the needs of Patient #6 upon facility arrival at 0416 for 4 hours and 35 minutes.

An interview on 06/23/2022 at 1025 with ED Director #14 revealed the facility had recently averaged 40-70 inpatients holding in the emergency department while caring for the emergency patients. The interview revealed the facility had staffing challenges that impacted the availability of staff to meet patient needs. The interview revealed the expectation for EMS staff offloading and ED staff accepting the patient was 30 minutes. The interview revealed that the department had experienced longer wait times and a decrease in satisfaction scores due to staffing issues.

An interview on 06/24/2022 at 1230 with Nurse Manager #16 revealed that the facility had created roles to assist with offloading the EMS staff, but it relied on staffing availability. The interview revealed that staffing the ED with qualified professionals like RNs, Paramedics, and ED Techs to meet the patient needs was a challenge and had impacted the level of care that patients received. The interview revealed that ED staff commonly took assignments with inpatients or behavioral health patients while caring for emergency patients.

Telephone interview on 06/28/2022 at 1500 with Paramedic #24 revealed she was one of the EMS providers that took care of Patient #6. Interview revealed Paramedic #24 received report from off going EMS staff. Interview revealed while waiting and monitoring Patient #6 to get an ED bed, Paramedic #24 transported Patient #6 to CT scan with hospital staff. Interview revealed an ED nurse gave Patient #6 IV medication prior to Paramedic #24 taking the patient to CT scan. Interview revealed Paramedic #24 and Patient #6 had to wait in the hallway outside the radio room for hours until an ED bed became available.

An interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. The interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

Telephone interview on 06/29/2022 at 1517 with Paramedic #25 revealed she transported Patient #6 to the ED. Interview revealed Patient #6's daughter reported Patient #6 normally walks and after dinner Patient #6 started leaning to one side when she was sitting upright. Interview revealed Patient #6 could not sit upright without leaning to the side. Interview revealed when EMS arrived in the ED, Paramedic #25 gave report to the triage nurse who was concerned about Patient #6. Interview revealed the triage nurse got a doctor to evaluate Patient #6. Interview revealed after the doctor evaluated Patient #6, Paramedic #25 waited with Patient #6 to get an ED bed. Interview revealed Patient #6 went from acting sweet to acting ugly and took off all her clothing. Interview revealed Paramedic #25 updated the triage nurse on the change in condition. Interview revealed Paramedic #25 was worried about the neurologic state of Patient #6 with the sudden change. Interview revealed Paramedic #25 handed Patient #6 off to the oncoming EMS crew at the end of her shift. Interview revealed Paramedic #25 estimated she monitored Patient #6 from around 0300 to 0800 when the next EMS crew took over. Interview revealed the EMS run sheet would have the exact times, but this was a rough estimate.



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5. Closed medical record review of Patient # 31 revealed a 92 year old female who presented to the facility's emergency department via EMS on 05/31/2022 at 1722 for a chief complaint of syncope. Review of the EMS patient care report revealed Patient #31 was alert and oriented with a BP of 132/89, pulse 81, respiratory rate 18. Review of EMS patient care report revealed "EMS arrives at receiving. One EMS crew member went into receiving to register patient. Triage notified EMS as long as patient had mask on patient could come inside to stage in hallway. With mask in place on patient, patient was transferred into receiving. EMS asked to stage in hallway until room became available. During wait time patient was assisted to bathroom. While waiting for room patient slept on stretcher. After extensive wait time, EMS asked triage if patient could be triaged due to patients stability and that there were ALS (advanced life support) interventions at that time. Triage nurse declined sitting she did not want patient to sit in the lobby with family due to syncopal episode as patient's chief complaint, Charge nurse was consulted and she advised patient could not be triaged for same. EMS notified the wait time could extend another 9 hours possibly. Patient and family were advised of further extended wait times. Patient and patient's family decided to take patient to another facility for treatment. Another set of vital signs were obtained, refusal..explained to them... EMS assisted patient transferring from wheelchair to front seat of POV (privately owned vehicle)." Patient #31 signed an EMS Refusal releasing them from EMS care. Review revealed Patient left EMS care at 2110. Review revealed patient care was never transferred to emergency department personnel and Patient #31 left the facility with family after waiting 3 hours and 48 minutes.

Interview on 06/29/2022 at 1015 with Paramedic #38 revealed she was the EMS personnel who transported Patient #31 to the emergency department. Interview revealed the patient's vital signs were stable and she was capable to sit in triage with family to prevent in a delay in triage. Interview revealed no nursing staff triaged the patient while waiting. Interview revealed revealed the emergency department staff say "she's your patient, she's in your care until we take report". Interview revealed the family was tired of waiting and wanted to take the patient to another hospital. Interview revealed EMS personnel made the charge nurse aware and the hospital staff do not speak to the patient's prior to departure. EMS staff assisted the patient to family's car.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

Interview on 06/24/2022 at 1250 with the previous Emergency Department Administrative Coordinator revealed when a patient voices a desire to leave the emergency department without completing treatment or a medical screening exam, a written refusal is attempted and risks and benefits are explained to the patient. Interview revealed the charge nurse is made aware and notifies the the physician. Interview revealed patients waiting with EMS staff for triage and room placement should also have a written refusal by emergency department staff prior to leaving the facility.

6. Closed medical record review of Patient #32 revealed a 67 year old female who presented to the facility's emergency department on 06/09/2022 at 1408 via EMS for a chief complaint of chest pain. Review of EMS patient care report revealed at 1408 "....Pt (patient) registered and report given to the triage nurse. No significant changes in pt condition while waiting for bed..." Review revealed at 1530 BP 102/57, pulse 72, oxygenation 94% and respiratory rate 12. Further review revealed at 1620 "Pt began complaining of increased r (right) sided chest pain radiating to her r arm. Nitroglycerin (medication used to treat chest pain), .4 MG via SL (sublingual) given (by named EMS Staff member)... Authorization:via Protocol. Pt response: Improved..." EMS report review revealed at 1908 "Pt stating she would like to leave ER AMA (against medical advise). Pt advised of possible consequences if leaving before being seen by a doctor. Pt verbalized understanding of possible consequences and signature obtained.." Record review revealed Patient #32 signed EMS refusal (5 hours after arrival). Review of facilty emergency department medical record revealed Patient #32 disposition set at 2043 "LWBS (left without being seen) before triage" and discharged at 2044.

Interview on 06/29/2022 at 1215 with Paramedic # 39 revealed he recalled Patient # 32. Interview revealed EMS staff had to treat the patient due to the complaint of chest pain. Interview revealed they have treatment protocols. Interview revealed the patient was tired of waiting. Interview revealed the ED staff never attempt to get a refusal of treatment from a patient waiting with EMS staff. Interview revealed he did notify ED staff Patient #32 was wanting to leave but they did nothing because Patient #32 was "still under the care of EMS staff in the hallway".

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

Interview on 06/24/2011 at 1250 with the previous Emergency Department Administrative Coordinator revealed when a patient voices a desire to leave the emergency department without completing treatment or a medical screening exam, a written refusal is attempted and risks and benefits are explained to the patient. Interview revealed the charge nurse is made aware and notifies the the physician. Interview revealed patients waiting with EMS staff for triage and room placement should also have a written refusal by emergency department staff prior to leaving the facility.



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7. Closed medical record review revealed Patient #28 was a 76-year-old male brought to the emergency department (ED) by emergency medical service (EMS) on 05/23/2022 with a complaint of vomiting. Review of the EMS run report revealed EMS arrived in the ED with Patient #28 at 2052. Review of the ED Timeline revealed the hospital documented Patient #28's arrival in the ED as 0139 (4 hours 47 minutes after EMS arrived with the patient). Review revealed the ED disposition was set to "LWBS before Triage" at 0142 (4 hours 50 minutes after EMS arrived with the patient). Review of the medical record revealed no MSE and no documentation of risk and benefits were discussed with Patient #28 by hospital staff prior to him leaving the ED.

Telephone interview on 06/28/2022 at 1359 with Paramedic #28 revealed he transported Patient #28 to the ED. Interview revealed when they arrived in the ED there were already 3 or 4 other EMS with stretchers with patients waiting to be seen. Interview revealed Paramedic #28 checked in with the triage nurse. Interview revealed a hospital staff member came to the stretcher and asked Patient #28 questions and then put a wrist band on the patient. Interview revealed after five hours waiting and not being see or evaluated, Patient #28 decided she was going to leave. Interview revealed Paramedic #28 notified the charge nurse of Patient #28 wanting to leave. Interview revealed the charge nurse notified Paramedic #28 the patient (Patient #28) did not need to sign anything for the hospital because they were not a patient of the hospital. Interview revealed Paramedic #28 had Patient #28 sign an EMS Refusal releasing them from EMS care. Interview revealed the hospital front desk staff called a taxi for Patient #28 to leave.

Interview on 06/29/2022 at 0948 with the ED Medical Director #9 revealed he felt there were no delays in performing timely Medical Screening Exams on patients that presented to the ED via EMS. Interview revealed that the EMS providers let the physicians know if there were issues with hallway patients awaiting triage and room placement.

Telephone interview on 06/29/2022 at 0904 with RN #27 revealed she vaguely remembered Patient #28. Interview revealed EMS brings the patients in, gives report to the charge nurse/coordinator and depending on the situation and if a bed is available, they either take the patient to a room or they stay with the patient until a room becomes available. Interview revealed RN #27 did not remember and probably did not talk with Patient #28 about risk of leaving without being seen nor the benefit of staying and being evaluated by a provider when a bed was available. RN #27 stated it is the nursing staff and/or the hospital staff responsibility to talk with the patient to explain they are trying to get a spot for the patient to be seen by the provider.

8. Closed medical record review revealed Patient #29 was a 53-year-old male brought to the emergency department (ED) by emergency medical service (EMS) on 06/13/2022 with a compl