The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.

NORTHWEST MEDICAL CENTER 6200 NORTH LA CHOLLA BOULEVARD TUCSON, AZ 85741 Feb. 4, 2015
VIOLATION: GOVERNING BODY Tag No: A0043
Based on observations, clinical record reviews, review of hospital policies and procedures, review of hospital logs and reports, and staff interviews, it was determined:

Tag A-395 (Nursing Services): The Governing Body failed to be accountable and ensure the provision of quality nursing services were provided to patients in the Emergency Department as evidenced by:

1. the hospital failed to ensure that 16 of 27 patients who presented to the Emergency Department, (ED) but left without being seen by a physician, were assessed by an RN (triaged) and/or reassessed prior to their leaving in accordance with hospital policies and procedures. This delay in triage time potentially affects the health and safety risk for each of these patients by delaying the evaluation and or diagnosis of an emergency medical condition. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #13, #14, #16, #17, #18, and #19); and the hospital failed to ensure the ED staff followed their policies and procedures that a qualified staff member inform 6 of 6 patients, who notified ED staff at the desk in the waiting room that they were leaving, of the risks of leaving prior to being seen by a physician. There is a risk of patients leaving the ED with an unidentified and untreated emergent medical condition if they have not been evaluated by a physician. (Patients #1, #2, #7, #12, #13, and #14.)


2. the hospital failed to ensure policies and procedures were followed for wound prevention and treatment for 3 of 3 inpatients who had skin breakdown in the sample of 13 inpatients; and that there was accurate and consistent documentation of skin assessments and wound care of patients who developed skin breakdown or had worsening of skin breakdown while hospitalized . The failure to follow policies and procedures with wound prevention and treatment has the potential risk of patients developing skin breakdown and/or worsening of existing skin breakdown. (Patients #20, #21, and #22).

Tag 1100 (Emergency Services): The Governing Body failed to ensure the provision of Emergency Services as evidenced by:

1. the hospital failed to ensure that 5 of 27 patients who presented to the Emergency Department (ED), were assessed (triaged) by a Registered Nurse (RN) to determine the nature of their chief complaint and to determine an acuity level. The amount of time ranged from 1 hour to 8.5 hours without being triaged before the patients left the waiting room. This delay in triage time potentially affects the health and safety risk for each of these patients by delaying the evaluation and or diagnosis of an emergency medical condition. (Patients #3, #5, #10, #11, and #17); and

2. the hospital failed to ensure the staff follow their policies and procedures and ensure that for 11 of 27 patients, who presented to the ED, they were reassessed while waiting in the ED waiting area, based upon their presenting complaints. Patients not being reassessed increases the risk for the patient's condition to change for the worse and not be recognized, and interventions initiated. (Patients #1, #2, #4, #6, #7, #8, #13, #14, #16, #18, and #19.) and

3. the hospital failed to ensure the ED staff follow their policies and procedures, and ensure that a qualified staff member inform 6 of 6 patients, who notified ED staff at the desk in the waiting room that they were leaving, of the risks of leaving prior to being seen by a physician. There is a risk of patients leaving the ED with an unidentified and untreated emergent medical condition if they have not been evaluated by a physician. (Patients #1, #2, #7, #12, #13, and #14.)


The cumulative effect of this systemic problem resulted in the hospital's inability to ensure the provision of quality health care.
VIOLATION: EMERGENCY SERVICES Tag No: A0092
Based on observations, clinical record reviews, review of hospital policies and procedures, review of hospital logs and reports, and staff interviews, it was determined the Governing Body failed to ensure the provision of Emergency Services as specified in the requirements of CFR 482.55 as evidenced by:

1. the hospital failed to ensure that 5 of 27 patients who presented to the Emergency Department (ED), were assessed (triaged) by a Registered Nurse (RN) to determine the nature of their chief complaint and to determine an acuity level. The amount of time ranged from 1 hour to 8.5 hours without being triaged before the patients left the waiting room. This delay in triage time potentially affects the health and safety risk for each of these patients by delaying the evaluation and or diagnosis of an emergency medical condition. (Patients #3, #5, #10, #11, and #17); and

2. the hospital failed to ensure the staff follow their policies and procedures and ensure that for 11 of 27 patients, who presented to the ED, they were reassessed while waiting in the ED waiting area, base dupon their presenting complaints. Patients not being reassessed increases the risk for the patient's condition to change for the worse and not be recognized, and interventions initiated. (Patients #1, #2, #4, #6, #7, #8, #13, #14, #16, #18, and #19.) and

3. the hospital failed to ensure the ED staff follow their policies and procedures, and ensure that a qualified staff member inform 6 of 6 patients, who notified ED staff at the desk in the waiting room that they were leaving, of the risks of leaving prior to being seen by a physician. There is a risk of patients leaving the ED with an unidentified and untreated emergent medical condition if they have not been evaluated by a physician. (Patients #1, #2, #7, #12, #13, and #14.)

Findings include:

The hospital's "CHS Compliance Policy/Procedure G2 A on the subject of EMTALA-Medical Screening/Stabilization included:

"1. Hospitals are obligated to perform the Medical Screening Examination to determine if an Emergency Medical Condition exists.
2. Medicare participating Hospitals that provide emergency services must provide a Medical Screening Examination to any individual regardless of diagnosis, financial status, race, color, national origin, handicap, ability to pay, or other protected category.
3. Individuals coming to the Dedicated Emergency Department must be provided a Medical Screening Examination. Triage is not equivalent to a Medical Screening Examination. Triage merely determines the 'order' in which patients will be seen, not the presence of absence of an Emergency Medical Condition.
4. The Medical Screening Examination includes both a generalized assessment and a focused assessment based on the patient's chief complaint, with the intent to determine the presence or absence of an Emergency Medical Condition.
5. A Hospital, regardless of size or patient mix, must provide screening and stabilizing treatment within the scope of its capabilities, as needed, to the individuals who come to the Hospital for examination and treatment."

The hospital's Policy/Procedure #: NMC-29.2, Emergency Medical Treatment and Patient Transfer, included: "If an individual refuses to consent to examination or treatment, after being informed of the risks and benefits and the Hospital's obligations under these rules, reasonable attempts shall be made to obtain a written refusal to consent to treatment or examination on the form provided for that purpose. The individual's medical record shall contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual."

The daily logs of patients who presented to the hospital's Emergency Department were reviewed for the following dates: 11/10/14, 11/11/14, and 11/12/2014 and 1/08/15, 1/09, 1/10/, 1/11, 1/12, 1/13, 1/14, 1/16, 1/17, 1/18, and 1/19/2015. The total number of patients who presented on those days ranged from 123 on 1/14/2015 to 157 on 1/09/2015. The following daily logs were identified to have a significantly high number of patients who left the ED without being seen by a physician:

-11/12/2014: 151 patients presented to the ED and 28 of those patients left without being seen by a physician, approximately 18.5%. In addition, 6 of the 28 patients left without being triaged.
-01/08/2015: 152 patients presented to the ED and 30 of those patients left without being seen by a physician, approximately 20%. Seven of the 30 patients left without being triaged.
-01/09/2015: 157 patients presented to the ED and 27 of those patients left without being seen by a physician, approximately 17%. Nine of the 27 patients left without being triaged.
-01/11/2015: 133 patients presented to the ED and 13 of those patients left without being seen by a physician, approximately 10%. Five of the 13 patients left without being
triaged.
-01/18/2015: 142 patients presented to the ED and 12 of those patients left without being seen by a physician, approximately 8%. Six of the 12 patients left without being triaged.

Refer to Tag A-395 for specific details of patients who were not assessed and reassessed by nursing staff while in the ED and left the ED without being seen by a physician.

The Hospital's "Refusal Form" located in six patient ED records included the following: "Leaving facility against advice...This is to certify that I am leaving the facility against the advice of the attending physician and the facility administration. I acknowledge that I have been informed of the risks involved and hereby release the attending physician, the facility and all personnel from all responsibility from ill effects which may result from this action." The bottom of the form included: "1. Patient verbalizes understanding of risks of refusal: ...1. Name of physician advising individual of risks and benefits.

There was no documentation in the six patient records that contained this form that the emergency room Technician and/or Registration Clerk who staffed the desk area of the waiting room notified nursing staff and/or a physician that the patient was leaving prior to being seen by a physician.

The Director of the Emergency Department, the Chief Nursing Officer, and the Medical Director of the Emergency Department, acknowledged during interviews, that they were not aware of the extent of patients leaving prior to being triaged, patients not being reassessed in the waiting room, and patients leaving prior to being evaluated without being informed of the risks of leaving in accordance to their own policies and procedures.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on clinical record reviews, review of hospital policies and procedures, review of hospital QAPI activities, and staff interviews, it was determined the hospital failed to ensure the quality improvement activities for wound care and hospital acquired pressure ulcers were implemented and monitored for success as evidenced by policies and procedures not followed for three inpatients who had pressure ulcers. Failure to follow policies and procedures with wound prevention and treatment has the potential risk to health and safety and potential outcomes of harm related to worsening skin breakdown (Patients #20, #21, and #22).

Findings include:

Refer to Tag A-395 for specific details relating to Patients #20, #21, and #22. Documentation in the clinical records specific to skin assessments and wound care were missing and/or inconsistent.

The hospital's Policy/Procedure titled Quality Improvement Plan Effective 6/16/2014, included: "Northwest Medical Center utilizes the CHS IDEA Cycle (Identify - Determine - Explore - Activate) as the model for Quality Improvement...Northwest Medical Center will implement a hospital-wide approach to systematically improve quality utilizing the IDEA Cycle method. Action is directed primarily at improving processes...Improvement opportunities are identified by departmental and organizational QI activities. . . Appropriate action will be recommended and implemented to eliminate or reduce variations identified or to improve quality of care...The effectiveness of any actions taken is assessed and documented. Periodic monitoring of the results of correction action, including re-design or processes, will be conducted to make sure that any problems identified have been alleviated or eliminated and sustained...If the specific area does not show improvement, new actions/design will be taken and, once again, the effectiveness will be assessed."

The Wound Care Nurse and the in-patient nursing staff revealed during interviews that there was not a clear understanding of the expectations and role of each other. The role of the Wound Care Nurse was not clearly defined and documented. It was also identified that the hospital was utilizing a significant number of agency nurses, traveler nurses and new graduate nurses.

The Director of Quality stated during an interview on 2/2/2015 that the hospital had a "Skin Team" who met on a quarterly basis to address wound care including hospital acquired skin breakdown (pressure ulcers, etc.). She reported data is collected monthly on patients admitted with skin breakdown and hospital acquired skin breakdown. According to the Director, the Skin Team consisted of the Wound Care Nurses, Department Heads, and Unit Directors. The Director reported there had been an increase in hospital acquired pressure ulcers and that a skin "SWAT Team" had been developed and implemented.

The Director of Wound Care was requested to join in the interview at that time. She stated the skin "SWAT Team" had been discussed but was never implemented because it was not approved by leadership.

The Director of Quality acknowledged she was not aware of this.

The surveyor requested documentation of the Skin Team Meeting Minutes and was provided a copy of meeting minutes dated 8/15/2014. The meeting was attended by the two Wound Care Nurses, the Wound Care Director, One Department Head and the Director of Quality. The Director reported there was another meeting in November which she did not attend nor did she have a copy of those minutes.

The last documentation of quality activities for healthcare acquired pressure ulcers was "[DATE]" in which the number of acquired skin breakdown was identified as well as the status of action items including obstacles encountered. There was no other documentation presented after that date that detailed current quality improvement activities and monitoring to decrease hospital acquired skin breakdown.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, clinical record reviews, review of hospital policies and procedures and staff interviews, it was determined:

Tag A-395:

1. the hospital failed to ensure that 16 of 27 patients who presented to the Emergency Department, (ED) but left without being seen by a physician, were assessed by an RN (triaged) and/or reassessed prior to their leaving in accordance with hospital policies and procedures. This delay in triage time potentially affects the health and safety risk for each of these patients by delaying the evaluation and or diagnosis of an emergency medical condition. (Patients #1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #13, #14, #16, #17, #18, and #19.); and the hospital failed to ensure the ED staff follow their policies and procedures, and ensure that a qualified staff member inform 6 of 6 patients, who notified ED staff at the desk in the waiting room that they were leaving, of the risks of leaving prior to being seen by a physician. There is a risk of patients leaving the ED with an unidentified and untreated emergent medical condition if they have not been evaluated by a physician. (Patients #1, #2, #7, #12, #13, and #14.)

2. the hospital failed to ensure policies and procedures were followed for wound prevention and treatment for 3 of 3 inpatients who had skin breakdown in the sample of 13 inpatients; and that there was accurate and consistent documentation of skin assessments and wound care of patients who developed skin breakdown or had worsening of skin breakdown while hospitalized . The failure to follow policies and procedures with wound prevention and treatment has the potential risk to health and safety and potential outcomes of harm related to worsening skin breakdown. (Patients #20, #21, and #22).

The cumulative effect of this systemic problem resulted in the hospital's inability to ensure the provision of quality health care.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, clinical record reviews, review of hospital policies and procedures and on staff interviews, it was determined:

1. the hospital failed to ensure that 16 of 27 patients who presented to the Emergency Department, (ED) but left without being seen by a physician, were assessed by an RN (triaged) and/or reassessed prior to their leaving in accordance with hospital policies and procedures. This delay in triage time potentially affects the health and safety risk for each of these patients by delaying the evaluation and or diagnosis of [DIAGNOSES REDACTED]#3, #4, #5, #6, #7, #8, #10, #11, #13, #14, #16, #17, #18, and #19.); and the hospital failed to ensure the ED staff follow their policies and procedures, and ensure that a qualified staff member inform 6 of 6 patients, who notified ED staff at the desk in the waiting room that they were leaving, of the risks of leaving prior to being seen by a physician. There is a risk of patients leaving the ED with an unidentified and untreated emergent medical condition if they have not been evaluated by a physician. (Patients #1, #2, #7, #12, #13, and #14.)


2. the hospital failed to ensure policies and procedures were followed for wound prevention and treatment for 3 of 3 inpatients who had skin breakdown in the sample of 13 inpatients; and that there was accurate and consistent documentation of skin assessments and wound care of patients who developed skin breakdown or had worsening of skin breakdown while hospitalized . The failure to follow policies and procedures with wound prevention and treatment has the potential risk to health and safety and potential outcomes of harm related to worsening skin breakdown. (Patients #20, #21, and #22).

Findings include:

1. A tour of the hospital's Emergency Department was conducted with the Director of the ED on 01/14/2015 and included observation of patient flow from the time they enter the ED. Patients walking in through the main doors go to a counter to sign in. This area is staffed with an emergency room Technician and a registration clerk. Patients are given an "Emergency Department Quick Registration" form to fill out with basic information including name, address and reason for the visit. The information is entered into the computer by the registration clerk and the patients wait in the waiting room until they are called to be triaged by a Registered Nurse.

1. The hospital's Policy/Procedure #: NMC- titled Triage-Emergency Department included:

"...POLICY: A Registered Nurse will perform a triage assessment on all patients presenting for care to the ED...PURPOSE: To facilitate a uniform and systematic approach to providing safe and timely care for patients (sic) presenting to the ED. The triage assessment does not constitute a medical screening exam. Triage is a rapid, focused patient assessment which provides an assignment of an acuity level based on the Emergency Severity Index (ESI) algorithm...DEFINITIONS: ESI: The Emergency Severity Index: The Emergency Severity Index (ESI) is a tool for use in emergency department (ED) triage. The ESI triage algorithm yields rapid, reproducible, and clinically relevant stratification of patients into fived (sic), groups, from level 1 (most urgent) to level 5 (least urgent). The ESI provides a method for categorizing ED patients by both acuity and resource needs...."

The hospital's Policy/Procedure #: NMC- titled Interdisciplinary Assessment/Reassessment included:

"...POLICY: Northwest Medical Center assesses and reassesses patients based upon their individual needs including physical, psychological and social/cultural status...1. Each patient is reassessed according to the guidelines established by the clinical discipline.
2. Once the patient has received an initial assessment/screen, subsequent reassessments will be done if indicated. The scope and intensity of these assessments are determined by the patient's diagnosis, care setting, the care the patient is seeking, the patient's consent to treatment, and his/her response to previous care...."

According to "Attachment A Assessment/Reassessment" the reassessment time frame of patient's in the ED is "At change in condition or 2 hours."

2. The hospital's Policy/Procedure #: NMC-9013 titled Refusal for Treatment (AMA) included:

"...POLICY: Northwest Medical Center (NMC) respects the right of a competent adult to refuse medical treatment to the extent permitted by law even when that refusal is likely to result in the patient's death...DEFINITIONS: ...3. Left With Out Treatment (LWOT): patient presents seeking care but leaves before being seen or treated by a physician. 4. Left before triage (LBT): Subcategory of LWOT in which the patient signs in at the Emergency Department, Urgent Care, or OB Triage but decides to leave the facility before triage. 5. Left Prior to Medical Screening Exam (LPMSE): Subcategory of LWOT in which the patient presents and requests evaluation at the Urgent Care, Emergency Department, or OB triage and leaves after triage but not before the Medical Screening Exam has been completed. . .INSTRUCTIONS: ...5. LEFT WITHOUT TREATMENT (LWOT)...a. LWOTS include patients who leave vefore (sic) triage (LBT) and patients who leave prior to Medical Screening Exam (LPMSE)...b. If a patient verbalizes they cannot wait to be seen either prior to triage or after triage but prior to the Medical Screening exam, if possible, an attempt is made for the UC/ED/OB nurse to talk with the patient prior to their departure...d. If the Patient leaves after triage but prior to a MSE (LPMSE) documentation will be added to the chart to indicate the patient left prior to the MSE and if known the reason for the departure...."

-Patient #1 came to the ED on 06/20/2014 at 8:19 a.m. with a chief complaint of "High blood pressure." Documentation in the clinical record revealed the patient was triaged by an RN at 8:29 a.m. who recorded two blood pressures at that time: 148/114 with a pulse of 102 and 174/111 with a pulse of 104. The patient's reported level of pain was "8" based on a 1 to 10 pain scale. The RN's assessment also included: "Pt (with) multiple complaints. C/o (complained of) high blood pressure uncontrolled. Pt out of psych meds. C/o (L) arm pain...Very anxious. (Positive for) TIA (transient ischemic attack). Documentation in the Focused Past Medical History section of the triage form revealed the patient had a history of hypertension and bipolar anxiety with medications included Seroquel (antipsychotic) and lorazepam (antianxiety).

The patient was sent back to the waiting room after triage and remained there until approximately 9:29 a.m. when she left without being evaluated by an ED physician. There was an illegible signature on the patient signature line of the hospital's "Refusal Form" The patient's date of birth (in a different handwriting) was on the Date/Time line next to the signature rather than the date of the signature and the time recorded under the patient's date of birth was "9:29." There was documentation in the "Risks/Benefits" section, "Stroke, Disability, Death," however; the RN who signed the form as a witness did not complete the section of the form that the patient verbalized an understanding of the risks of refusing treatment. There was no documentation as to why the patient wanted to leave and there was no documentation that the patient's high blood pressure and pulse were rechecked before she left.

-Patient #2 was a patient over the age of 80 who went to the ED on 01/09/2015 at 10:31 a.m. with a chief complaint of "rectal bleeding." The patient was triaged by an RN at 10:41 a.m. who documented: "Rectal bleeding since this morning. Denies pain." There was no documentation that the RN questioned the patient about the amount of bleeding or a description of the bleeding (dark, bright red, etc.). The patient's blood pressure was documented as "233/74" and her oxygen saturation level was 92%. There was no documentation that the RN addressed the patient's high blood pressure and the patient was sent back to the waiting room.

Documentation revealed the patient left the waiting room at 1:57 p.m. without being seen by a physician. The patient signed the hospital's Refusal Form, however, it was not dated, there was no documentation of why the patient left or that she was informed of the risks of leaving prior to being seen by a physician. There was no documentation she was reassessed by nursing staff during the greater than three hour period she was in the waiting room.

-Patient #3 was a pediatric patient under the age of 12-months who was taken to the ED on 01/22/2015 at 3:30 p.m. The documented reason for visit on the Emergency Department Quick Registration form was the pediatric patient had a: "High fever 102 (degrees), cough, phlegm, and pain." Documentation on a "Discharge Instructions (Clinical" form revealed an ED Departure Time of "17:14 (5:14 p.m.). There was no documentation in the clinical record that the pediatric patient was triaged between the arrival time of 3:30 p.m. and departure time of 5:15 p.m., a period of one hour and 45 minutes.

-Patient #4 went to the ED on 01/16/2015 at 5:29 p.m. The patient's reason for visit documented on the Emergency Department Quick Registration form was: "My sugar is high 447, trouble breathing." The patient was triaged by the RN at 6:29 p.m., one hour after her arrival. The RN documented: "pt with high finger stick at home, 353 in triage." The normal reference range for blood glucose is 70-100 mg/dl. There was no documentation the RN questioned the patient to determine if she had a history of diabetes and was on insulin or an oral diabetic medication and if so, when the patient had last taken the medication. The ED Departure Time recorded in the Clinical Discharge Instructions form was "22:17" (10:17 p.m.). There was no documentation that the patient was seen by a physician nor documentation that she was reassessed after the triage time of 6:29 p.m. and departure time of 10:17 p.m., a period of approximately 3.75 hours.

-Patient #5 was a pediatric patient under the age of 6 weeks taken to the ED on 01/09/2015 at 11:10 p.m. The reason for the ED visit documented by the patient's mother on the Emergency Department Quick Registration form was "Baby is throwing up." There was no documentation that the infant was triaged between the time of arrival at 11:10 p.m. and the documented ED Departure Time of 12:22 a.m. on 01/10/2015, a period of approximately one hour and ten minutes.

-Patient #6 was a pediatric patient under the age of 16 months taken to the ED on 11/12/2014 at 5:25 p.m. because of a "rash, fever, cough." The patient was triaged at 6:24 p.m., over one hour later. The RN's assessment of the patient revealed the patient had: "...scattered red rash to torso and legs." The infant's temperature was 99.0 degrees (rectal). The RN documented the infant's immunizations were current. Even though the patient had symptoms of [DIAGNOSES REDACTED].m., a period of approximately 2.5 hours after she was triaged. There was no documentation the infant was reassessed or evaluated by a physician during that time.

The infant was taken by her mother to one of the Urgent Care Clinics associated with the hospital on [DATE] at 9:30 a.m., where she was evaluated by a Nurse Practitioner and diagnosed with [DIAGNOSES REDACTED]

An interview was conducted on 01/15/2015 with the hospital's Infection Control Preventionist and the Manager of the ED. The Infection Control Preventionist reported that based on the infants symptoms of [DIAGNOSES REDACTED].m. to approximately 9 p.m., a period of approximately 3.5 hours where members of the general public were potentially exposed.

-Patient #7 was over the age of 90 and arrived in the hospital's ED on 01/08/2015 at 6:19 p.m., with "Chest Pain." The patient was triaged at 6:33 p.m., and the triage note included: "ankles and feet swollen onset 2 weeks ago increasing, hx (history) of COPD/CHF (congestive heart failure) on fluid restriction no weight gain. New onset A fib (atrial fibrillation) at MD office today controlled rate." The patient returned to the waiting room after the triage. The patient's clinical record included an ECG dated 01/08/2015 at 11:29 p.m., over 5 hours after her arrival. The ECG was reviewed by an ED physician who documented it did not meet criteria for STEMI (ST elevation myocardial infarction). However, documentation on the ECG revealed: "Atrial fibrillation...Right axis deviation. . . ST & T wave abnormality, consider inferolateral ischemia or digitalis effect...Abnormal ECG." The patient remained in the waiting room until 1 a.m. on 01/09/2015 when she left. There was no documentation in the record that a nursing reassessment was performed between the time she was triaged at 6:33 p.m. and when she left at 1 a.m. on 01/09/2015, a period of approximately 6.5 hours.

The patient signed the hospital's Refusal Form. There was a check mark in the box next to "Leaving facility against advice." There was no documentation on the form or anywhere in the clinical record that a qualified staff member informed the patient of the risks of leaving without being seen by a physician. There was no documentation the patient was made aware of the "Abnormal ECG" prior to her leaving.

-Patient #8 was over the age of 70 years and went to the hospital's ED on 01/08/2015 at 2:28 p.m. with "back pain between shoulder blades" per her cardiologist instructions to go to the ED. The patient was triaged approximately 45 minutes later at 3:16 p.m. The RN documented the patient had back pain between her shoulder blades and had "chest pressure" at the time of triage. An ECG was performed at 3:28 p.m. and revealed: "Sinus bradycardia with sinus arrhythmia...Left axis deviation...Abnormal ECG." The ECG was reviewed by an ED physician who signed it and documented the ECG did not meet STEMI criteria.

The patient was returned to the waiting room where she remained until she left without being evaluated by a physician. Documentation in the Clinical Discharge Instructions form revealed an ED Departure Time of 7:49 p.m., a period of approximately 4.5 hours after she was triaged. There was no documentation the patient who had an "abnormal ECG" was reassessed by nursing staff during that time.

-Patient #9 went to the ED on 01/10/2015 at 6:10 p.m. with "heart issues." The patient was triaged at 6:12 p.m. at which time the RN documented the patient complained of shortness of breath and heart palpitations for two hours. An ECG was performed at 6:13 p.m. and revealed: "Possible left atrial enlargement...RSR or QR pattern in V1 suggest right ventricular conduction delay...Borderline ECG." An ED physician reviewed it on or around 6:16 p.m. and documented it did not meet the criteria for a STEMI.

The patient was returned to the waiting room where she remained until she left without being evaluated by a physician. Documentation in the Clinical Discharge Instructions form revealed an ED Departure Time of 12:48 a.m. on 1/11/2015, a period of approximately 6.5 hours after she was triaged. There was no documentation the patient who had a "borderline ECG" was reassessed by nursing staff during that time.

-Patient #10 went to the ED on 1/19/2015 at 5 p.m. for "bleeding 9 weeks pregnant." There was no documentation of any attempt made to triage the patient and the ED Departure Time documented in the Clinical Discharge Instructions form was 1:50 a.m. on 1/20/2015, approximately 8.5 hours after her arrival.

-Patient #11 went to the ED on 01/18/2015 at 7:52 p.m. for "ankle, hip pain." which was accident related. There was no documentation of any attempt made to triage the patient and the ED Departure Time documented in the Clinical Discharge Instructions form was 12:01 a.m. on 1/19/2015, approximately 4 hours after her arrival.

-Patient #13 went to the ED on 01/18/2015 at 7:23 p.m. for nausea and vomiting. The patient was triaged at 8:15 p.m. and the RN implemented the "ED Back Pain Protocol" that included obtaining a urine specimen for a urinalysis and blood for labwork. The protocol included intravenous (IV) fluids, Normal Saline 1000 mL, to be started at 10 mL/hr. Documentation in the record revealed a urine sample was obtained from the patient and sent to the lab for a urinalysis. An ER Technician documented at 8:34 p.m. that two attempts were made to obtain blood for the physician ordered labwork but the attempts were "unsuccessful." There was no documentation this was communicated to an RN. There was no documentation that the physician ordered IV fluids were started or why they were not started.

There was no documentation the patient was evaluated by a physician and at 10:44 p.m., approximately 2.5 hours after she was triaged, the patient signed the hospitals Refusal Form. An "X" was in the box next to the statement "Leaving facility against advice." There was no documentation that the patient was reassessed by nursing staff or any further attempts to collect blood for the labwork and start the IV fluids ordered by the physician during that time. There was no documentation the patient was informed of the risks of leaving prior to leaving without being seen by a physician.

-Patient #14 went to the ED on 11/11/2014 at 12:41 p.m. for nausea, vomiting, and diarrhea. The patient was triaged at 1:14 p.m. and the RN documented the patient reported the symptoms started four days prior. The patient also reported she fell that day and injured her right hip with a pain level of "8." Documentation in the record revealed she had a history of hypertension, however, there was no blood pressure recorded during the triage assessment.

The patient left the waiting room on or around 3:57 p.m. without being seen by a physician. The patient signed the hospital's Refusal Form at 3:57 p.m. There was no documentation as to why the patient was leaving nor documentation that she was informed of the risks of leaving prior to being evaluated by a physician.

-Patient #16 came to the ED on 01/09/2015 at 9:26 p.m. with abdominal pain, nausea and vomiting. The patient was triaged approximately 2 hours later at 11:24 p.m. The patient's pain level was documented to be "8." The patient was given an acuity level of "4 - Less Urgent." It was noted that the patient had been at one of the hospital's Urgent Care facilities earlier that day where she was evaluated and discharged around 5:35 p.m. Documentation in the clinical record revealed the patient left the ED at 1:15 a.m. on 01/10/2015 without being seen by a physician.

The patient returned to the ED on 01/11/2015 at 6:43 p.m. for "Severe stomach pain/nausea." Documentation revealed the patient had left the ED by the time she was called to be triaged at 7:34 p.m., almost 1 hour later.

The patient went to another hospital in Tucson on that date and arrived at 8:13 p.m. where she was triaged, evaluated by an ED physician and admitted as an in-patient. Documentation in that clinical record revealed the patient went to surgery the following morning, 01/12/2015. Documentation in the surgeon's Operative Report included: Very distended, very thick walled gallbladder with 3 large stones impacted in the neck. Gangrenous changes of the gallbladder wall...Multiple portions of the wall were gangrenous especially against the hepatic surface."

-Patient #17 went to the ED on 01/18/2015 at 8:30 p.m. for "Difficulty Breathing." Documentation in the clinical record revealed the patient had left the ED when she was called to be triaged at 9:35 p.m., one hour after her arrival.

The patient returned to the ED on 01/19/2015 at 11:48 p.m., again for "Difficulty Breathing" and was triaged at 12:09 a.m. on 1/20/2015. The patient was evaluated by an ED physician who diagnosed the patient with Asthma exacerbation.

-Patient #18 went to the ED on 11/11/2014 at 10:27 p.m. for difficulty breathing and "sharp" chest pains. The patient was triaged at 10:46 p.m. and the RN documented the patient reported a sudden onset of trouble breathing with burning to the mid epigastric area. Documentation in the record revealed the RN performed a blood draw for labwork and obtained a urine specimen for a urinalysis.

Documentation in the Clinical Discharge Instructions form revealed an ED Departure Time of 4 a.m. on 11/12/2014, a period of approximately 6.5 hours after she was triaged. There was no documentation the patient was reassessed by the nursing staff or evaluated by a physician during that time.

-Patient #19 went to one of the hospital's Urgent Care facilities on 01/19/2015 where he was evaluated and sent "directly" to the hospital's ED for further evaluation and treatment. He arrived at the ED at 6:54 p.m. and was triaged at 7:36 p.m. The RN documented the patient had abdominal pain with nausea and vomiting with a pain rating of "9." Documentation revealed the RN implemented the ED Back Pain Protocol at 7:40 p.m. which included starting IV fluids (Normal Saline 1000cc at 10/ml per hour; urinalysis and blood for labwork). The urinalysis was obtained, however, there was no documentation blood was obtained and sent to the lab nor was an IV started and IV fluids initiated. According to documentation in the Clinical Discharge Instructions, the patient's ED Departure Time was 1:44 a.m. on 01/20/2015, approximately 6 hours after he was triaged. There was no documentation the patient was seen by a physician nor documentation that the patient was reassessed by the nursing staff during that time.

The patient returned to the ED on 01/20/2015 at 11:28 a.m. and was triaged, evaluated by an ED physician and admitted for abdominal pain and elevated liver function tests.

The above clinical records were reviewed with the Director of the Emergency Department who acknowledged policies and procedures were not followed for triage, assessments and reassessments, and for patient's leaving without being seen by a physician.

2. The hospital's Policy/Procedure titled Wound Photography, NMC-5013.02, included: "...POLICY: 1. Photograph(s) are used as an adjunct to assessment documentation to support the written wound documentation for pressure ulcers present on admission and occurring during admission...PURPOSE: 1. To document initial condition of the patient's wound/skin upon admission. 2. To document clear, accurate status of skin conditions. 3. To document objective images of treatment outcomes for referral. 4. To facilitate communication between team and physicians...PROCEDURE:...a. Upon discovery of pressure ulcers, notify the physician and the Wound Care Team. b. Utilizing the Physician Order write a nursing order for 'Photography of wound.' c. If after hours (past 1500 Monday-Friday or Weekends) notify Administrative Nursing Supervisor to take the photo...Photograph all pressure ulcers and other wounds deemed appropriate by physicians or WOCN team...The recommended frequency for taking photographs of hospital acquired injuries is...Photograph all pressure ulcers noted on admission and or discovery and every 2 weeks throughout admission...When there is any significant decline or improvement in the skin or wound condition...Photographer to document in the patient's medical record and wound photographic log the area(s) that were photographed...."

The hospital's Policy/Procedure titled Pressure Ulcer Prevention, NMC- , included: "...POLICY: Pressure Ulcer Prevention interventions are performed to protect patients identified as moderate risk to high risk for skin breakdown, based on the nursing assessment or by physician order...PROCEDURE...a head-to-toe skin assessment is completed on admission and every shift throughout admission. Document findings in the EMR (electronic medical record)...Skin assessments, including areas covered by prevention dressings, are to be assessed every shift with findings documented in the EMR...."

Another hospital Policy/Procedure titled Wound Care Medication Protocol, NMC-4022.48, included: "...POLICY: Northwest Medical Center (NMC) provides care for patients with skin breakdown associated with complications resulting in wounds due to trauma, infection, compromised vascular status, pressure injuries, and manifestations of diabetes mellitus, neuropathy, surgery, atypical wounds, incontinence and ostomy management, managed by the Wound & Skin Team...GUIDELINES: 1. If a patient develops skin breakdown or presents with a condition upon admission without wound care orders in place or new considerations develop: a. A Wound Care consult to 'Evaluate and Treat, Per Protocol' is obtained by Physician Order. b. The Wound Care Team shall respond within 72 hours to implement a plan of care...."

-Patient #20 was admitted on [DATE], and was still an in-patient at the time of the survey. Documentation in the History and Physical dated 12/19/2014, identified: "...the elderly patient who lived alone was found on the floor in her home..." The patient was not able to provide a clear history at the time of her arrival, however, the physician documented: "...The patient has been down for at least 1 to 2 days...."

The first nursing documentation of the patient's skin assessment was on 12/19/2014 at 9 p.m. by a "Graduate Nurse" who documented the patient had a "Pressure ulcer" on her left buttock and right buttock. The Graduate Nurse documented in the sections for "Skin Abnormality Color" for both areas: "Red, Black, Pink." The dressing for both areas was documented to be Mepilex, which is an absorbent foam dressing.

On 12/20/2014 at 8 a.m. an RN documented five areas of skin breakdown as follows:
-Left Buttock: Type: "Pressure ulcer." The measurements were: 1 centimeter (cm) in length and 1 cm in width with surrounding redness.
-Right Buttock: Type: "Pressure ulcer." The measurements were: 3 cm in length and 2 cm in width with surrounding redness.
-Right Hip: Type: "Blister." The measurements were: 10 cm in length and 7 cm in width with the surrounding skin tissue "Boggy." The RN also documented the patient had facial bruising to both eyes and forehead.

There was a physician's order dated 12/20/2014 at 8:38 a.m. for "Consult to Wound Care Nurse...wounds upon admit, bilateral buttocks with wounds...."

On 12/21/2014 at 8 a.m. the RN documented another area of bruising to the back of the patient's right knee and a "Laceration" on the patient's upper face There was no documentation that the bruise or laceration were measured.

On 12/23/2014 at 8 a.m. the RN documented the measurements of a "Tear" to the back of the patient's right knee: 2 cm in length and 2 cm in width. The RN also documented the areas on the patient's left and right buttocks to be "Abrasion" which were previously documented to be pressure ulcers.

On 12/25/2014 at 8 p.m. the RN documented those areas to be "scratches."

The patient was not seen by the Wound Care Nurse until 12/23/2014, three days after the 12/20/2014 physician's order for same. The Wound Care Nurse's documentation included: "...pt has abrasions to forehead and diffuse echymosis (bruising). There is a 12 x 12 x 0.1 cm serous filled blister with [DIAGNOSES REDACTED]tous (sic), non blanchable wound base to her r (right) hip. There are two partial thickness dime sized erosions to her bilateral buttocks at her ischium..." The RN documented the areas on the patient's buttocks were: "...Friction vs stage II pressure ulcers POA (present on admission)..." There was no other documentation that the Wound Care Nurse measured the "dime sized erosions" on the patient's buttocks.

The nursing daily documentation of the areas of breakdown were not consistent. For example, on 12/26/2014 at 8 a.m. the RN documented "Abrasion" on the left buttock; "Scratches" on the right buttock and right hip; and "Pressure ulcer" on "Sacrum Midline" which had not been previously identified. The area was described as "pink" however, there was no other description including the size.

On 12/28/2014 the Graduate Nurse documented the areas on the right and left buttocks were pressure ulcers.

The patient's skin was not reassessed by the Wound Care Nurse until 01/09/2015, seventeen days after the first consult. The documentation included: "There is linear shaped area in coccyx/gluteal cleft that is dark pink, non blanchable, Stage 1 PU (pressure ulcer). The Wound Care Nurse did not document the size of the area. She documented she would recommend the use of Vasolex to the patient's buttocks and coccyx.

Review of the physician orders revealed the physician entered an order for Vasolex twice a day to those areas.

Review of the nursing documentation revealed inconsistent documentation of the dressing changes. On 1/10/2015 at 8 a.m., the RN documented dressing changes to the right and left buttocks with Vasolex but no documentation of a dressing change to the coccyx area.

A "Graduate Nurse" also documented on 1/10/25 at 7 pm dressing changes to the right and left buttocks but not to the coccyx.

On 1/11/2015 at 10:56 a.m. the RN documented a dressing change to the pressure ulcer on the patient's "right thigh" but not to any other areas.

There were several days that no documentation of dressing changes were performed including the nursing "Integumentary entries as follows: 1/11/2015 at 7 p.m. (Traveler RN); 1/12/2015 at 8 a.m.; 1/12/2015 at 1:52 p.m.; 1/12/2015 at 8 p.m.; 1/13/2015 at 12:42 a.m.; and 1/13/2015 at 8:49 a.m. There was no way to determine from the nursing documentation in the clinical records provided to the surveyor as to exactly how many areas of skin breakdown the patient had; where the areas were; the size of the areas; what they looked like; whether or not dressing changes were being performed following physician orders; and whether or not the areas were improving or deteriorating.

The Wound Care Nurse did not assess the patient again until 01/20/2015, eleven days later. Her documentation on that date included: "...PU in gluteal cleft/coccyx area has deteriorated. Area is open with layer adherent soft yellow slough, some removed with cleaning. There is small amount serious drainage...Will recommend d/c Vasolex and changing dressing to Iodoflex pad..." The Wound Care Nurse did measure the area on this date, however, because she did not measure it the first time she identified it on 1/9/2015, it is not known if the area is larger. The next Wound Care Nurse consult was on 1/26/2015: "...Coccyx wound is slightly improved, yellow slough has loosened, some cut away, revealing granulation tissue underneath. This is Stage III PU, deteriorated from Stage 1 to Stage III..."

-Patient #21 was admitted on [DATE] after falling at home and fracturing her left hip. She had surgery on 1/15/2015 to repair the fracture. The patient's general skin integrity was documented to be "Intact" when assessed on 1/13/2015 at 4 p.m.; on 1/14/2015 at 8 a.m.; on 1/15/2015 at 8 a.m.; on 1/16/2015 at 8 p.m.; on 1/17/2015 at 8 p.m.; on 1/18/2015 at 8 a.m. and 11 p.m.; on 1/19/2015 at 9:45 a.m.; on 1/22/2015 at 8 a.m.; on 1/25/2015 at 8 p.m.; on 1/26/2015 at 8 a.m.; and 1/28/2015 at 8 a.m.

Wound Care Nurse #1 documented on 1/17/2015 at 1:45 p.m.: "...pt has a loose, serious filled blister to her right buttock. skin is intact. there is a sacral mepilix over this approx 2 x 1.8 cm...trauma/friction vs pressure ulcer POA (present on admission)- vasolex bid (two times a day)...ordered..." According to the skin assessments documented above, the patient did not have skin breakdown when she was admitted as documented by Wound Care Nurse #1. There was no other documentation by a Wound Care Nurse and nursing documentation of skin assessments from 1/25/2015 to 1/29/2015 revealed the patient had a "pressure u
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on observations, review of clinical records, review of hospital policies and procedures, review of Emergency Department logs, and on staff interviews, it was determined hospital policies and procedures were not followed to ensure patients received emergency services as evidenced by:

Refer to Tag A-0092 Emergency Services for details related to this Condition

1. the hospital failed to ensure that 5 of 27 patients who presented to the Emergency Department (ED), were assessed (triaged) by a Registered Nurse (RN) to determine the nature of their chief complaint and to determine an acuity level. The amount of time ranged from 1 hour to 8.5 hours without being triaged before the patients left the waiting room. This delay in triage time presents a potential health and safety risk for outcomes of harm for each of these patients. (Patients #3, #5, #10, #11, and #17); and

2. the hospital failed to ensure the staff follow their policies and procedures and ensure that for 11 of 27 patients, who presented to the ED, they were reassessed while waiting in the ED waiting area, based upon their presenting complaints. Patients not being reassessed increases the risk for the patient's condition to change for the worse and not be recognized, and interventions initiated. (Patients #1, #2, #4, #6, #7, #8, #13, #14, #16, #18, and #19.) and

3. the hospital failed to ensure the ED staff follow their policies and procedures, and ensure that a qualified staff member inform 6 of 6 patients, who notified ED staff at the desk in the waiting room that they were leaving, of the risks of leaving prior to being seen by a physician. There is a risk of patients leaving the ED with an unidentified and untreated emergent medical condition if they have not been evaluated by a physician. (Patients #1, #2, #7, #12, #13, and #14.)

The effect of this systemic problem resulted in the hospital's inability to ensure the provision of quality and safe emergency services to patients with potential medical emergencies.