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Based on observation and staff interview, it was determined the facility failed to ensure all drugs and biologicals used in life-saving procedures were not expired and readily available for all patients receiving care in the facility. This had the potential for patients' health and safety to be compromised in the event of a medical emergency. Findings include:

An observation of the ED was conducted in the presence of the CNO on 11/15/18, beginning at 9:15 AM.

1. The facility's crash cart was inspected, and the following emergency drugs were expired:

- Verapamil, expired 11/01/18

- Levophed, expired 8/01/18

- Bacteriostatic water, expired 2/01/18

- Nitrobid, expired 9/2018

- Sodium chloride, expired 11/15/18

The CNO was interviewed on 11/15/18, beginning at 9:32 AM, and she confirmed the emergency drugs were expired.

2. The facility's Broslowe cart was inspected, and 12 of 14 "Broslowe Pediatric Emergency System" kits were expired.

The CNO was interviewed on 11/15/18, beginning at 9:32 AM, and she confirmed the emergency pediatric kits were expired.

The facility failed to ensure all drugs and biologicals used in life-saving procedures were not expired.

Based on observation and staff interview, it was determined the facility failed to ensure emergency medical equipment was maintained. This had the potential for patients' health and safety to be compromised in the event of a medical emergency. Findings include:

An observation of the ED was conducted in the presence of the CNO on 11/15/18, beginning at 9:15 AM.

The following emergency equipment was expired:

- Two, 20 G IV catheters, expired 2/2017

- 18 G IV catheter, expired 3/2017

- 16 G IV catheter, expired 3/2017

- Central line kit, expired 1/2016

- Suture kit, expired 8/2018

- Intracath kit, expired 3/2000

- Multiple chest tubes, expired 3/1992

The CNO was interviewed on 11/15/18, beginning at 9:32 AM, and she confirmed the emergency equipment was expired.

The facility failed to ensure medical equipment was maintained.

Based on medical record review, policy review, and staff interview, it was determined the CAH failed to ensure healthcare services were provided in accordance with appropriately written policies for 2 of 2 ED patients (#1 and #2) who were discharged and whose records were reviewed. This resulted in discharge instructions not being provided to assist patients in their care planning. Findings include:

A facility policy "DISCHARGE INSTRUCTIONS" revised 8/11/2004, stated "Every patient treated in the Emergency Room will on discharge receive discharge instructions appropriate to the treatment received. The patient or the patient representative will be asked to sign a statement acknowledging receipt of discharge instructions." This policy was not followed. Examples include:

1. Patient #2 was a 16 year old female who was seen in the ED on 2/16/18, with a diagnosis of acute appendicitis. She was discharged the same day on 2/16/18.

Patient #2's medical record included a discharge summary, dated 2/16/18, signed by the PA. The summary included a section titled "Education," which had a signature line for the RN and Patient #2 to sign. This section was blank.

The CEO was interviewed on 11/14/18, beginning at 4:15 PM, and Patient #2's medical record was reviewed in her presence. She stated she was unaware patients were required to sign their discharge instructions. The CEO confirmed the facility did not follow their discharge policy.

The facility failed to follow their discharge policy for Patient #2.



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2. Patient #1 was a 12 year old male who was seen in the ED on 7/03/18, with a diagnosis of pain in the finger of the right hand. He was discharged the same day on 7/03/18.

Patient #1's medical record included a discharge summary, dated 7/03/18, signed by the PA. The summary included a section titled "Education," which had a signature line for the RN and Patient #1 to sign. This section was blank.

The CEO was interviewed on 11/14/18, beginning at 4:15 PM, and Patient #1's medical record was reviewed in her presence. She stated she was unaware patients were required to sign their discharge instructions. The CEO confirmed the facility did not follow their discharge policy.

The facility failed to follow their discharge policy for Patient #1.

Based on governing body meeting minutes review, medical staff meeting minutes review, personnel roster review, and staff interview, it was determined the facility failed to ensure policies were developed with the advice of mid-level practitioners. This had the potential for outdated policy information, which could impact delivery of patient care and health care processes. Findings include:

A facility personnel roster, dated 11/05/18, included the following mid-level practitioners:

- 3 Physician Assistants

- 1 Nurse Practitioner

Fifteen governing body meeting minutes, from October 2017 to October 2018, were reviewed. The meeting minutes did not include policy development and review by facility mid-level practitioners.

Nine medical staff meeting minutes, from October 2017 to October 2018, were reviewed. The meeting minutes did not include policy development and review by facility mid-level practitioners.

The CNO was interviewed on 11/15/18, beginning at 10:02 AM. When asked if mid-level practitioners participated in policy development and review, she stated she "thought so," however, she confirmed this development and review was not documented.

The facility failed to ensure policies were developed with the advice of the mid-level practitioners.

Based on medical record review, facility policy review, and staff interview, it was determined the facility failed to ensure patients' medical records included all vital sign assessments for 1 of 2 patients (Patient #2) who were discharged and whose medical records were reviewed. This had the potential for incomplete information made available to practitioners to determine appropriate care. Findings include:

A facility policy "ER Service Level RN initial assessment (C201)," undated, stated "At a minimum, each patient presenting will have taken by the RN on duty:...Complete vital signs." This policy was not followed.

Patient #2 was a 16 year old female who was seen in the ED on 2/16/18, with a diagnosis of acute appendicitis. She was discharged the same day on 2/16/18.

From Patient #2's initial ED presentation on 2/16/18 at 4:47 PM, to her discharge on 2/16/18 at 8:41 PM, there were no recorded vital signs. It was unclear if Patient #2's condition improved, stayed the same, or worsened during her ED visit.

The CNO was interviewed on 11/15/18, beginning at 10:02 PM, and Patient #2's medical record was reviewed in her presence. She confirmed Patient #2's ED record did not include vital sign assessments.

The facility failed to ensure Patient #2's medical record included all vital sign assessments.

Based on review of governing body and medical staff meeting minutes, and staff interview, it was determined the facility failed to ensure annual evaluation of the facility's health care policies was performed. This prevented the facility from determining whether its policies were complete and reflected the care staff provided to patients. Findings include:

Fifteen governing body meeting minutes, from October 2017 to October 2018, were reviewed. The meeting minutes did not include annual policy evaluation.

Nine medical staff meeting minutes, from October 2017 to October 2018, were reviewed. The meeting minutes did not include annual policy evaluation.

The CNO was interviewed on 11/15/18, beginning at 10:02 AM. When asked if the facility evaluated its policies annually, she stated "yes, but it's not documented."

The facility failed to ensure annual evaluation of the facility's health care policies was performed.