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.

PACIFICA HOSPITAL OF THE VALLEY 9449 SAN FERNANDO RD SUN VALLEY, CA 91352 Aug. 4, 2016
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on observation, interview and record review, the facility failed to:

1. Ensure information about the facility's grievance process, including whom to contact to file a grievance and, the phone number and address for lodging a grievance with the appropriate State agency was available for patients or the patient' representatives (A118);

2. Ensure effective operation of the grievance process when the Quality Director (QD - responsible for the grievance process) failed to implement the facility internal grievance procedure according to the facility policy and procedure (A119);

3. Ensure information on the facility's grievance procedure was provided to patients or patient representatives (A121);

4. Ensure written notices were sent to patients or patient representatives when grievances were resolved (A123);

5. Ensure two of two suicidal patients (Patients 28 and 29) in the Emergency Department (ED) were provided with a safe environment when they were placed in a room next to an exit door with no staff present to monitor them (A144);

6. Ensure the plan of care was modified when seclusion and restraint were initiated for violent or self-destructive behavior, for six of ten sampled patients (Patients 5, 6, 8, 9, 12, and 22) (A166);

7. Ensure seclusion and restraint were applied in accordance with a physician's order when five of ten sampled patients ( Patient 5, 6, 7, 10 and 12) were placed in simultaneous seclusion and restraint without a physician's order for seclusion (A168);

8. Ensure eight of ten sampled patients placed in simultaneous seclusion and restraint (Patients 5, 6, 7, 8, 9, 12, 22, and 26) had face-to-face evaluations by a physician, a trained Registered Nurse (RN), or physician assistant (PA) within one hour after the initiation of seclusion and restraint (A178); and,

9. Ensure the face-to-face evaluation, for one of one sampled patient (Patient 10) placed in simultaneous seclusion and restraint, addressed three of four required elements:
- the patient's reaction to the seclusion and restraint,
- the patient's medical and behavioral condition, and
- the need to continue or terminate the seclusion and restraint (A179).

The cumulative effect of these systemic problems resulted in failure to ensure patients rights were being promoted and protected in a safe and effective manner.
VIOLATION: PATIENT RIGHTS: GRIEVANCES Tag No: A0118
Based on interview and record review, the facility failed to ensure information about the facility's grievance process, including whom to contact to file a grievance and, the phone number and address for lodging a grievance with the appropriate State agency was available for patients or the patients' representatives.

This failure had the potential to result in unsafe practices as a result of unidentified and uncorrected grievances.
Findings:

On August 2, 2016, at 11:30 a.m., the Admission Clerk (AC) was interviewed. The AC stated that his responsibility was to check patients in for admission. The AC stated the admission packets provided to patients included information on conditions of admission, advance directive and patient rights. The AC stated he did not discuss the grievance process with patients or the patients' representatives.

On August 2, 2016, the admission packet was reviewed. The document titled "Patient Rights" indicated "You have the right to:...23. File a grievance and/or file a complaint with the State Department of health Services and/or the hospital and be informed of the action taken." There was no information indicating how to file a grievance with the facility, whom to contact to file a grievance with the facility and the phone number and address of the State agency.

There was no other facility document/material to indicate patients or the patients' representatives were informed of the facility's internal grievance process, who to contact to file a grievance with the facility or the phone number and address of the State agency.
VIOLATION: PATIENT RIGHTS: REVIEW OF GRIEVANCES Tag No: A0119
Based on interview and record review, the facility failed to ensure effective operation of the grievance process when the Quality Director (QD) who was responsible for the grievance process failed to implement the facility internal grievance procedure according to the facility policy and procedure.

This failure had the potential to result in unsafe practices as a result of unidentified and uncorrected grievances.

Findings:

On August 2, 2016, the facility policy and procedure "COMPLAINTS - PATIENTS, FAMILIES, VISITORS" revised May 2014 was reviewed. The policy and procedure indicated, "...Patient Grievance = a formal or informal written or verbal complaint regarding the patient's care, abuse or neglect made to the hospital by the patient or a patient's representative...A complaint that cannot be resolved promptly by the staff present and meets the above definition of a "patient grievance" is elevated to a level of grievance...A patient grievance requires a written response be forwarded to the complainant, informing him/her of the final disposition. This written notice must include the following:
- Name of the hospital contact person
- Steps taken on behalf of the patient to investigate the grievance
- Results of the grievance process
- Date of completion of the grievance process..."

On August 2, 2016, at 9:30 a.m., the Quality Director (QD) was interviewed. The QD stated he was responsible for the facility grievance process. The QD stated he did not separate complaints from grievances. The QD stated he was not sure which entries on the complaint and grievance log were written or verbal grievances, incident reports, or complaints. The QD stated he sent written notices of resolution to patients or the patients' representatives, "sometimes." The QD further stated, "I should have read the policy and procedure."
VIOLATION: PATIENT RIGHTS: GRIEVANCE PROCEDURES Tag No: A0121
Based on interview and record review, the facility failed to ensure information on the facility's grievance procedure was provided to patients/and or patient representatives.

This failure had the potential to result in unsafe practices as a result of unidentified and uncorrected grievances.


Findings:

On August 2, 2016, at 11:30 a.m., the Admission Clerk (AC) was interviewed.
The AC stated that his responsibility was to check patients in for admission. The AC stated the admission packets provided to patients included information on conditions of admission, advance directive and patient rights. The AC stated he did not discuss the grievance process with patients or the patients' representatives.
The AC stated if a patient and/or the patient's representative had a complaint or grievance he instructed them to go to the receptionist.

On August 2, 2016, the admission packet was reviewed. The document titled "Patient Rights" indicated "You have the right to:...23. File a grievance and/or file a complaint with the State Department of health Services and/or the hospital and be informed of the action taken." There was no information indicating how to file a grievance with the facility and whom to contact to file a grievance with the facility.

There was no other facility document/material to indicate patients and/or patient representatives were informed of the facility's internal grievance process and who to contact to file a grievance with the facility.

On August 2, 2016, at 11:45 a.m., the receptionist was interviewed. The receptionist stated when patients or the patients' representatives had a complaint or grievance she asked them to fill out the, "CUSTOMER GRIEVANCE/COMPLAINT FORM." The receptionist stated she was not aware of any other document/material informing patients and/or patient representatives on how to file a grievance or whom to contact to file a grievance in the facility.

On August 2, 2016, at 12 noon, the Medical/Surgical Unit Desk Clerk (MSC) and Medical/Surgical Unit Charge Nurse (CN) were interviewed. Both the MSC and CN stated they had never seen the, "CUSTOMER GRIEVANCE/COMPLAINT FORM." Both the MSC and CN stated they were not aware of the facility internal grievance process. They stated they do not discuss the process with patients or patients' representatives. Both the MSC and CN stated they were not aware of any document to indicate patients or patient representatives were informed of the facility's internal grievance process or who to contact to file a grievance with the facility.

On August 2, 2016 the facility policy and procedure, "COMPLAINTS - PATIENTS FAMILIES AND VISITORS," revised May 2014, indicated "To provide a means of recording, responding to, and tracking patient complaints and grievances in order to provide optimal quality of care and customer satisfaction...Complaints and grievances are documented by completing a "Customer Grievance/Complaint Report."..."
VIOLATION: PATIENT RIGHTS: NOTICE OF GRIEVANCE DECISION Tag No: A0123
Based on interview and record review, the facility failed to ensure written notices were sent to patients or patient representatives when grievances were resolved.

This failure violated the patient's right to be informed of the outcome of the investigation.

Findings:

On August 2, 2016, at 9:30 a.m., the Quality Director (QD) was interviewed. The QD director stated he did not separate complaints from grievances. The QD stated he sent written notices resolution, "sometimes." The QD further stated, "I should have read the policy and procedure."

The facility policy and procedure "COMPLAINTS - PATIENTS, FAMILIES, VISITORS" reviewed May 2014, indicated "...Patient Grievance = a formal or informal written or verbal complaint regarding the patient's care, abuse or neglect made to the hospital by the patient or a patient's representative...A patient grievance requires a written response be forwarded to the complainant, informing him/her of the final disposition. This written notice must include the following:
- Name of the hospital contact person,
- Steps taken on behalf of the patient to investigate the grievance,
- Results of the grievance process,
- Date of completion of the grievance process..."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to ensure two of two suicidal patients (Patients 28 and 29) in the Emergency Department (ED) were provided with a safe environment when they were placed in a room next to an exit door with no staff present to monitor them. This failed practice resulted in the potential for:

a. The patients to leave the department without staff knowledge: and,

b. Self injury, up to, and including suicide.

Findings:

During a tour of the ED on August 1, 2016, at 11:25 a.m., accompanied by the ED Director (EDD), two patients were observed sitting on gurneys in Room 4. There was no staff observed sitting in or around the room.

Room 4 was located next to a door marked, "EXIT," that led out to the main hallway. The hallway had doors at each end of the facility (three total) that exited the building into different areas of the parking lot.

During a concurrent interview with the EDD, he stated psychiatric patients were, "usually," placed in Room 4 while they waited for beds to become available in the inpatient psychiatric unit. The EDD stated the two patients in Room 4 were probably voluntary psychiatric patients (presented to the ED for voluntary psychiatric treatment/admission). He stated if they were involuntary psychiatric patients (5150 patients - placed on a 72 hour hold against their will due to being a danger to themselves or others, or being unable to safely care for themselves), they would, "be on a one-to-one" (continuous monitoring by a staff member to prevent escape, self injury, or violence).

The record for Patient 28 was reviewed on August 1, 2016. Patient 28, a [AGE] year old female, presented on August 1, 2016, at 38 minutes after midnight, on a 5150 for being a danger to herself, with suicidal thoughts and a previous suicide attempt. The nurse's notes indicated the patient appeared to be depressed, sad, anxious, unpredictable, and impulsive. The record indicated Patient 28 was to be admitted to the inpatient psychiatric unit when a bed became available. The record indicated a one-to-one sitter was assigned to monitor the patient at 1:36 a.m., and remained throughout the night shift (ending at 7 a.m.). There was no indication the one-to-one monitoring continued during the day shift.

The record for Patient 29 was reviewed on August 1, 2016. Patient 29, a [AGE] year old male, presented on July 31, 2016, at 6:15 p.m., on a 5150 for being a danger to himself, with suicidal thoughts and threats to hurt himself. The record indicated Patient 29 was to be admitted to the inpatient psychiatric unit when a bed became available. The nurse's notes indicated a one-to-one male sitter was assigned to monitor him for safety throughout the night (ending at 7 a.m.). There was no indication the one-to-one monitoring continued during the day shift.

During an interview with the ED security officer (EDSO) on August 1, 2016, at 11:35 a.m. (with the same two patients in Room 4 and no staff present in or around the room), the EDSO stated he was assigned as the second security officer in the ED for the day. He stated his assignment was to roam the ED to, "keep the peace." The EDSO stated the two patients in Room 4 were 5150 patients, and they should be on a one-to-one, with a staff member watching them to make sure they did not leave.

The EDSO stated there was no certified nursing assistant (CNA) available to monitor the patients, so he was helping them. He stated he did not want to, "watch," them all of the time because they, "needed their space," and he might be violating their right to privacy, so he just kept his eyes on the general area so they did not leave.

The EDSO stated the patients would not be able to exit through the door next to their room (Room 4), because they would have to push a button to get the door to open.

At 11:45 a.m., the surveyor pushed on the exit door next to ED Room 4. The door opened into the main facility hallway. Two exits to the parking lot were observed down the hallway to the left. One exit to the parking lot was observed down the hallway to the right.

During an interview with ED Registered Nurse (EDRN) 1 (who was caring for the patients in Room 4) on August 1, 2016, at 11:50 a.m., EDRN 1 stated the ED did not have the CNA staffing to provide one-to-one monitoring that day, so there was no monitoring being done on the patients. The RN stated the patients should have been on one-to-one monitoring.

During an interview with the EDD on August 1, 2016, at 11:55 a.m., the EDD stated both patients in Room 4 were on one-to-one monitoring until the morning change of shift (at 7 a.m.), when a new CNA should have come in to monitor them. The EDD stated the day shift CNA did not come in, so the patients were not being monitored on a one-to-one basis (for 4 hours and 45 minutes at that time).

The facility policy titled, "One on One Observation," was reviewed on August 1, 2016. The policy indicated any patient with severe suicidal intent (has a plan and means [ability] to commit suicide) may be placed on one-to-one acuity staffing, and the charge nurse would assign a CNA to provide the one-to-one observation. According to the policy, the CNA assigned to the patient would:

a. Stay within arms distance of the patient at all times, and maintain visual contact at all times;

b. Assess the patient for any changes in condition and report their findings to the charge nurse;

c. Communicate with the patient continuously; and,

d. Ask for assistance when needed.

Both suicidal patients in the ED were placed on one-to-one monitoring after arriving and demonstrating the need to be monitored. The one-to-one monitoring was discontinued due to staffing without an assessment indicating there was no need for it. Both patients were at risk for leaving the ED through the door next to their room, and harming or killing themselves.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0166
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure the plan of care was modified when seclusion and restraint were initiated for violent or self-destructive behavior, for six of ten sampled patients (Patients 5, 6, 8, 9, 12, and 22).

This failure had the potential to result in violent or self-destructive behavior to continue without measures developed and implemented to prevent recurrence.

Findings:

1. On August 2, 2016, Patient 5's record was reviewed. Patient 5 was admitted to the facility on on [DATE], with diagnoses that included [DIAGNOSES REDACTED]

A physician's order dated May 28, 2016, at 7:54 a.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing restraint clinical note dated May 28, 2016, at 7:59 a.m., indicated, "Time restraint applied:-7:45 ...Description of Safety Risks leading to action...DESTRUCTION OF HOSPITAL PROPERTY, SELF INJURY BEHAVIOR, THREATENING (sic) TOWARD STAFF."

The nursing restraint clinical note dated May 28, 2016, at 8:17 a.m., indicated, "Time restraints removed:-815..."

The May/June 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 5 was in seclusion and restraint for 30 minutes, on May 28, 2016.

There was no documented evidence the plan of care was modified to address the initiation of seclusion and restraint for Patient 5.

2. On August 2, 2016, Patient 6's record was reviewed. Patient 6 was admitted to the facility on on [DATE], with diagnoses that included [DIAGNOSES REDACTED]

A physician's order dated June 9, 2016, at 8:22 a.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing restraint clinical note dated June 9, 2016, at 8:20 a.m., indicated, "...throwing punches and kicking staff...Pt (patient) very hostile and agitated, was places in seclusion (sic) and
restraints @ (at) 08:15...for safety..."

The nursing restraint clinical note dated June 9, 2016, at 9:05 a.m., indicated, "Time restraints removed:-0901..."

The May/June 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 6 was in seclusion and restraint for 46 minutes on June 9, 2016.

There was no documented evidence the plan of care was modified to address the initiation of seclusion and restraint for Patient 6.

3. On August 2, 2016, Patient 8's record was reviewed. Patient 8 was admitted to the facility on on [DATE], for psychiatric evaluation.

A physician's order dated May 11, 2016, at 10:25 a.m., indicated, "...seclusion...to ensure physical safety..."

A physician's order dated May 11, 2016, at 10:26 a.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing restraint clinical note dated May 11, 2016, at 10:20 a.m., indicated, "Time restraint applied:-1020...PT (patient) STARTED BANGING HEAD ON WALL AND ATTEMPTED TO BITE ARMS..."

The nursing restraint clinical note dated May 11, 2016, at 11:04 a.m., indicated, "Time restraints removed:-1100..."

The May 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 8 was in seclusion and restraint for 40 minutes on May 11, 2016.

There was no documented evidence the plan of care was modified to address the initiation of seclusion and restraint for Patient 8.

4. On August 2, 2016, Patient 9's record was reviewed. Patient 9 was admitted to the facility on on [DATE], with diagnoses that included [DIAGNOSES REDACTED]

A physician's order dated May 23, 2016, at 10:55 a.m., indicated, "...seclusion...to ensure physical safety..."

A physician's order dated May 23, 2016, at 10:58 a.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing clinical note dated May 23, 2016, at 3:41 p.m.., indicated, "...UPON ADMISSION TO BHU (behavioral health unit), PT (patient) STARTED ASSAULTING STAFF...SECLUSION AND RESTRAINT WAS ALSO ORDERED...PT IS SLEEPING IN HIS BED AFTER HE WAS REMOVED FROM (sic) SECLUSION AND RESTRAINTS..."

The May 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 9 was in seclusion and restraint for 50 minutes on May 23, 2016.

There was no documented evidence a plan of care was developed and implemented to address the initiation of seclusion and restraint for Patient 9.

5. On August 2, 2016, Patient 12's record was reviewed. Patient 12 was admitted to the facility on on [DATE], with diagnoses that included [DIAGNOSES REDACTED]

A physician's order dated April 23, 2016, at 9:40 a.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing restraint clinical note dated April 23, 2016, at 9:40 a.m., indicated, "Time restraint applied:-933...PT. (patient) CAME IN UNIT SCREAMING ACTING AGGRESSIVELY TOWARDS STAFF, UNABLE TO REDIRECT..."

The nursing restraint clinical note dated April 23, 2016, at 10:58 a.m., indicated, "Time restraint removed:-1023..."

The APRIL 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 12 was in seclusion and restraint for 50 minutes on April 23, 2016.

There was no documented evidence the plan of care was modified to address the initiation of seclusion and restraint for Patient 12.





6. On August 2, 2016, Patient 22's record was reviewed. Patient 22 was brought to emergency department on a 5150 hold (involuntary hold due to danger to self or others). On July 2, 2016, at 6:20 p.m., Patient 22 was placed in restraints as he was banging his head, hitting at staff, and threatening his father.

Patient 22 was involuntarily admitted to the facility on on July 2, 2016, at 11:01 p.m. Patient 22's diagnosis included schizoeffective disorder (a mental illness characterized by schizophrenia [hallucinations].

On July 3, 2016, at 5 p.m., the nurse documented Patient 22 approached staff in a threatening manner, medications were given but the patient became more aggressive. At 5:17 p.m., staff notified the physician who ordered physical restraints and seclusion.

A physician's order dated July 3, 2016, at 5:16 p.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist... and Seclusion."

The nursing restraint clinical note dated July 3, 2016, at 5:17 p.m., indicated "Time restraint applied: 5:17 p.m., time discontinued 5:47 p.m."

There was no documented evidence the plan of care was modified to address the initiation of seclusion and restraint for Patient 22.

On August 3, 2016, at 9 a.m., the records of Patients 5, 6, 8, 9, 12, and 22 were reviewed with the Behavioral Health Unit Director (BHUD). The BHUD confirmed the care plans were not modified for the initiation of seclusion and restraint for Patients 5, 6, 8, 9, 12, and 22.

The facility policy and procedure, "SECLUSION AND RESTRAINTS" revised June 30, 2016, indicated, "...modify the patients plan for care..."

The facility policy and procedure titled, "CARE PLAN, INTERDISCIPLINARY," with a last revised date of December 2014, was reviewed. The policy indicated a plan of care was developed for all patients to promote continuity and optimal patient care. The "Plan of care will reviewed and updated, as patient needs change...Any significant changes in the patient's condition will be addressed immediately in the plan of care..."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0168
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview and record review, the facility failed to ensure seclusion and restraint were applied in accordance with a physician's order. Five of ten sampled patients ( Patient 5, 6, 7, 10 and 12) were placed in simultaneous seclusion and restraint without a physician's order for seclusion.

This failed practice resulted in the potential for unnecessary use of simultaneous seclusion and restraint.

Findings:

On August 1, 2016, at 2 p.m., a tour of the Behavioral Health Unit (BHU) was conducted with the Chief Nursing Officer (CNO) and BHU Director (BHUD). The BHU seclusion room was observed. The seclusion room was locked and a key was required to get in and to leave the room (seclusion / involuntary confinement, a room from which the patient is physically prevented from leaving, i.e. locked door). The CNO and BHUD stated this was their only seclusion room. The CNO and BHUD also stated this was the only room where they can apply four or five point restraints. The CNO and BHUD stated when four or five point restraints were initiated for patients they are "automatically" placed in the seclusion room (resulting in simultaneous seclusion and restraint).

On August 2, 2016 at 1:30 p.m., the BHUD was interviewed in the seclusion room. The BHUD stated, "If the patient is in restraint, the patient is also in seclusion." The BHUD further stated every time there was an order for restraint there should also be an order for seclusion, "since that's what we are doing."

1. On August 2, 2016, Patient 5's record was reviewed. Patient 5 was admitted to the facility on on [DATE], with diagnoses that included [DIAGNOSES REDACTED]

A physician's order dated May 28, 2016, at 7:54 a.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing restraint clinical note dated May 28, 2016, at 7:59 a.m., indicated, "Time restraint applied:-7:45 ...Description of Safety Risks leading to action...DESTRUCTION OF HOSPITAL PROPERTY, SELF INJURY BEHAVIOR, THREATENING (sic) TOWARD STAFF."

The nursing restraint clinical note dated May 28, 2016, at 8:17 a.m., indicated, "Time restraints removed:-815..."

The May/June 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 5 was in seclusion and restraint for 30 minutes, on May 28, 2016.

There was no documented evidence in Patient 5's record of a physician's order to place patient in seclusion.

2. On August 2, 2016, Patient 6's record was reviewed. Patient 6 was admitted to the facility on on [DATE], with diagnoses that included [DIAGNOSES REDACTED]

A physician order dated June 9, 2016, at 8:22 a.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing restraint clinical note dated June 9, 2016, at 8:20 a.m., indicated, "...throwing punches and kicking staff...Pt (patient) very hostile and agitated, was places in seclusion (sic) and restraints @ (at) 08:15...for safety..."

The nursing restraint clinical note dated June 9, 2016, at 9:05 a.m., indicated, "Time restraints removed:-0901..."

The May/June 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 6 was in seclusion and restraint for 46 minutes on June 9, 2016.

There was no documented evidence in Patient 6's record of a physician's order to place patient in seclusion.

3. On August 2, 2016, Patient 7's record was reviewed. Patient 7 was admitted to the facility on on [DATE], for psychiatric evaluation.

A physician's order dated June 10, 2016, at 3 p.m.., indicated "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing clinical note dated June 10, 2016, at 3:37 p.m., indicated, "...Pt became assaultive...Pt imminent danger to others, was placed in S/R (seclusion/restraint), 5 point leather restraint applied...Pt was released from S/R [at] 15:50..."

The "SECLUSION AND LEATHER RESTRAINTS FLOW SHEET" dated June 6, 2016, indicated seclusion and leather restraints were initiated at 3:05 p.m. and discontinued at 3:50 p.m.

The May/June 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 7 was in seclusion and restraint for 45 minutes on June 10, 2016.

There was no documented evidence in Patient 7's record of a physician's order to place patient in seclusion.

4. On August 2, 2016, Patient 10's record was reviewed. Patient 10 was admitted to the facility on on [DATE], with diagnoses that included [DIAGNOSES REDACTED]

A physician's order dated May 6, 2016, at 3:51 p.m.., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing clinical note dated May 6, 2016, at 5:20 p.m. indicated, "...PT (patient) TO BE ESCORTED TO SECLUSION ROOM. RESTRAINTS APPLIED AT 1545 (3:45 p.m.)...all rights restored at 1735 (5:35 p.m.)..."

The "SECLUSION AND LEATHER RESTRAINTS FLOW SHEET" dated May 6, 2016, indicated seclusion and leather restraints were initiated at 3:45 p.m. and discontinued at 5:35 p.m.

The April 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 10 was in seclusion and restraint for 1 hour and 50 minutes, on May 6, 2016.

There was no documented evidence in Patient 10's record of a physician's order to place patient in seclusion.

5. On August 2, 2016, Patient 12's record was reviewed. Patient 12 was admitted to the facility on on [DATE], with diagnoses that included [DIAGNOSES REDACTED]

The physician order dated April 23, 2016, at 9:40 a.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing restraint clinical note dated April 23, 2016, at 9:40 a.m., indicated, "Time restraint applied:-933...PT. (patient) CAME IN UNIT SCREAMING ACTING AGGRESSIVELY TOWARDS STAFF, UNABLE TO REDIRECT..."

The nursing restraint clinical note dated April 23, 2016, at 10:58 a.m., indicated, "Time restraint removed:-1023..."

The APRIL 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 12 was in seclusion and restraint for 50 minutes on April 23, 2016.

There was no documented evidence in Patient 12's record of a physician's order to place patient in seclusion.

On August 2, 2016, at 2:30 p.m., the records of Patient 5, 6, 7, 10 and 12 were reviewed with the BHUD. The BHUD confirmed there were no physician's orders for Patient 5, 6, 7, 10 and 12 to be in seclusion when they were placed in simultaneous seclusion and restraint.

The facility policy and procedure "SECLUSION AND RESTRAINTS" revised June 30, 2016 was reviewed. The policy and procedure did not indicate obtaining physician orders for placing patients in seclusion is required.
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0178
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure eight of ten sampled patients placed in simultaneous seclusion and restraint (Patients 5, 6, 7, 8, 9, 12, 22, and 26) had face-to-face evaluations by a physician, a trained Registered Nurse (RN), or physician assistant (PA) within one hour after the initiation of seclusion and restraint.

This failed practice resulted in the patients not being evaluated in order to determine if a serious medical or psychological condition existed, and/or to determine if the continued use of seclusion and/or restraints was necessary.

Findings:
1. On August 2, 2016, Patient 5's record was reviewed. Patient 5 was admitted to the facility on on [DATE], with diagnoses that included [DIAGNOSES REDACTED]

A physician's order dated May 28, 2016, at 7:54 a.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing restraint clinical note dated May 28, 2016, at 7:59 a.m., indicated, "Time restraint applied:-7:45 ...Description of Safety Risks leading to action...DESTRUCTION OF HOSPITAL PROPERTY, SELF INJURY BEHAVIOR, THREATENING (sic) TOWARD STAFF."

The nursing restraint clinical note dated May 28, 2016, at 8:17 a.m., indicated, "Time restraints removed:-815..."

The May/June 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 5 was in seclusion and restraint for 30 minutes, on May 28, 2016.

There was no documented evidence in Patient 5's record of a face-to-face evaluation by a physician, a trained RN, or PA within one hour after the initiation of the intervention of restraints and seclusion.

2. On August 2, 2016, Patient 6's record was reviewed. Patient 6 was admitted to the facility on on [DATE], with diagnoses that included [DIAGNOSES REDACTED]

A physician's order dated June 9, 2016, at 8:22 a.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing restraint clinical note dated June 9, 2016, at 8:20 a.m., indicated, "...throwing punches and kicking staff...Pt (patient) very hostile and agitated, was places in seclusion (sic) and restraints @ (at) 08:15...for safety..."

The nursing restraint clinical note dated June 9, 2016, at 9:05 a.m., indicated, "Time restraints removed:-0901..."

The May/June 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 6 was in seclusion and restraint for 46 minutes on June 9, 2016.

There was no documented evidence in Patient 6's record of a face-to-face evaluation by a physician, a trained RN, or PA within one hour after the initiation of the intervention of restraints and seclusion.

3. On August 2, 2016, Patient 7's record was reviewed. Patient 7 was admitted to the facility on on [DATE], for psychiatric evaluation.

A physician order dated June 10, 2016, at 3 p.m.., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing clinical note dated June 10, 2016, at 3:37 p.m., indicated, "...Pt became assaultive...Pt imminent danger to others, was placed in S/R (seclusion/restraint), 5 point leather restraint applied...Pt was released from S/R @ 15:50..."

The "SECLUSION AND LEATHER RESTRAINTS FLOW SHEET" dated June 6, 2016, indicated seclusion and leather restraints were initiated at 3:05 p.m. and discontinued at 3:50 p.m.

The May/June 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 7 was in seclusion and restraint for 45 minutes on June 10, 2016.

There was no documented evidence in Patient 7's record of a face-to-face evaluation by a physician, a trained RN, or PA within one hour after the initiation of the intervention of restraints and seclusion.

4. On August 2, 2016, Patient 8's record was reviewed. Patient 8 was admitted to the facility on on [DATE], for psychiatric evaluation.

A physician's order dated May 11, 2016, at 10:25 a.m., indicated, "...seclusion...to ensure physical safety..."

A physician's order dated May 11, 2016, at 10:26 a.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing restraint clinical note dated May 11, 2016, at 10:20 a.m., indicated, "Time restraint applied:-1020...PT (patient) STARTED BANGING HEAD ON WALL AND ATTEMPTED TO BITE ARMS..."

The nursing restraint clinical note dated May 11, 2016, at 11:04 a.m., indicated, "Time restraints removed:-1100..."

The May 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 8 was in seclusion and restraint for 40 minutes on May 11, 2016.

There was no documented evidence in Patient 8's record of a face-to-face evaluation by a physician, a trained RN, or PA within one hour after the initiation of the intervention of restraints and seclusion.

5. On August 2, 2016, Patient 9's record was reviewed. Patient 9 was admitted to the facility on on [DATE], with diagnoses that included [DIAGNOSES REDACTED]

A physician order dated May 23, 2016, at 10:55 a.m., indicated, "...seclusion...to ensure physical safety..."

A physician order dated May 23, 2016, at 10:58 a.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing clinical note dated May 23, 2016, at 3:41 p.m.., indicated "...UPON ADMISSION TO BHU (behavioral health unit), PT (patient) STARTED ASSAULTING STAFF...SECLUSION AND RESTRAINT WAS ALSO ORDERED...PT IS SLEEPING IN HIS BED AFTER HE WAS REMOVED FROM (sic) SECLUSION AND RESTRAINTS..."

The May 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 9 was in seclusion and restraint for 55 minutes on May 23, 2016.

There was no documented evidence in Patient 9's record of a face-to-face evaluation by a physician, a trained RN, or PA within one hour after the initiation of the intervention of restraints and seclusion.

6. On August 2, 2016, Patient 12's record was reviewed. Patient 12 was admitted to the facility on on [DATE], with diagnoses that included [DIAGNOSES REDACTED]

A physician's order dated April 23, 2016, at 9:40 a.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing restraint clinical note dated April 23, at 2016, 9:40 a.m., indicated "Time restraint applied:-933...PT. (patient) CAME IN UNIT SCREAMING ACTING AGGRESSIVELY TOWARDS STAFF, UNABLE TO REDIRECT..."

The nursing restraint clinical note dated April 23, 2016, at 10:58 a.m., indicated, "Time restraint removed:-1023..."

The APRIL 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 12 was in seclusion and restraint for 50 minutes on April 23, 2016.

There was no documented evidence in Patient 12's record of a face-to-face evaluation by a physician, a trained RN, or PA within one hour after the initiation of the intervention of restraints and seclusion.






7. On August 2, 2016, Patient 22's record was reviewed. Patient 22 was brought to emergency department on a 5150 hold (involuntary hold due to danger to self or others). On July 2, 2016, at 6:20 p.m., Patient 22 was placed in restraints as he was banging his head, hitting at staff, and threatening his father.

Patient 22 was involuntarily admitted to the facility on on July 2, 2016, at 11:01 p.m. Patient 22's diagnosis included schizoeffective disorder (a mental illness characterized by schizophrenia [hallucinations] and either bipolar or major depression) and polysubstance abuse (use of multiple addictive substances).

On July 3, 2016, at 5 p.m., the nurse documented Patient 22 approached staff in a threatening manner, medications were given but patient became more aggressive. At 5:17 p.m., staff notified the physician who ordered physical restraints and seclusion.

The physician's order dated July 3, 2016, at 5:16 p.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist... and Seclusion."

The nursing restraint clinical note dated July 3, 2016, at 5:17 p.m., indicated, "Time restraint applied: 5:17 p.m., time discontinued 5:47 p.m." Patient 22 was in seclusion and restraint for 30 minutes.

There was no documented evidence in Patient 22's record of a face-to-face evaluation by a physician, a trained RN, or PA within one hour after the initiation of the intervention of restraints and seclusion.

8. On August 2, 2016, Patient 26's record was reviewed. Patient 26 was voluntarily admitted to the facility on on [DATE], at 11:50 a.m., with diagnosis that included schizo-effective disorder, depressive type.

A physician's order dated June 14, 2016, at 9:10 a.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist...the use of seclusion is clinically justified."

On June 14, 2016, at 9:10 a.m., the nurse documented the patient was an imminent danger to others as he was "beating another patient." According to documentation, Patient 26's restraints were removed at 9:40 a.m.. Patient 26 also left the seclusion room at this time. Patient 26 was in seclusion and restraint for 30 minutes.

There was no documented evidence in Patient 26's record of a face-to-face evaluation by a physician, a trained RN, or PA within one hour after the initiation of the intervention of restraints and seclusion.

On August 2, 2016, at 5:23 p.m., the Chief Nursing Officer (CNO) was interviewed. The CNO stated, "We only do face to face with the physician if the restraint is more than 59 minutes."

The facility policy and procedure, "SECLUSION AND RESTRAINTS" revised June 30, 2016, indicated, "...The face to face evaluation must occur by the LIP (licensed independent practitioner) within one (1) hour of restraint application..."
VIOLATION: PATIENT RIGHTS: RESTRAINT OR SECLUSION Tag No: A0179
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure the face-to-face evaluation, for one of one sampled patient (Patient 10) placed in simultaneous seclusion and restraint, addressed three of four required elements:
- the patient's reaction to the seclusion and restraint,
- the patient's medical and behavioral condition, and
- the need to continue or terminate the seclusion and restraint.

This failed practice resulted in the potential for unnecessary and prolonged use of restraint and/or seclusion.

Findings:

On August 2, 2016, Patient 10's record was reviewed. Patient 10 was admitted to the facility on on [DATE], with diagnoses that included schizophrenia (mental illness characterized by a disconnection from reality).

A physician's order dated May 6, 2016, at 3:51 p.m., indicated, "Leather Locked Limb (restraint) - Right ankle...Left ankle...Right wrist...Left Wrist..."

The nursing clinical note dated May 6, 2016, at 5:20 p.m. indicated, "...PT (patient) TO BE ESCORTED TO SECLUSION ROOM. RESTRAINTS APPLIED AT 1545 (3:45 p.m.)...all rights restored at 1735 (5:35 p.m.)..."

The "SECLUSION AND LEATHER RESTRAINTS FLOW SHEET" dated May 6, 2016, indicated seclusion and leather restraints were initiated at 3:45 p.m. and discontinued at 5:35 p.m.

The April 2016 "DENIAL OF RIGHTS & SECLUSION/RESTRAINTS MONTHLY REPORT" indicated Patient 10 was in seclusion and restraint for 1 hour and 50 minutes, on May 6, 2016.

On August 3, 2016, at 11:45 a.m., the Chief Nursing Officer (CNO) was interviewed. The CNO stated the document,"Restraints / Seclusion Consultation Form," was the form that physicians use to document face to face evaluations. The "Restraints / Seclusion Consultation Form" dated May 6, 2016, at 4:45 p.m. for Patient 10 was reviewed with the CNO. The CNO confirmed the document did not indicate the required elements of a face to face evaluation were addressed.

The facility policy and procedure, "SECLUSION AND RESTRAINTS" revised June 30, 2016, indicated "...The face to face evaluation must occur by the LIP (licensed independent practitioner) within one (1) hour of restraint application...evaluation includes...The patient's reaction to the intervention, The patient's medical and behavioral condition and the need to continue or terminate the restraint or seclusion..."
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, and record review, the facility failed to ensure:

1. Seven of seven Obstetrical (OB) nurses (OB RN 1, OB RN 2, OB RN 3, OB RN 4, OB RN 5, OB RN 6, and OB RN 7), demonstrated competence in performing an obstetrical evaluation (a standardized procedure) prior to assigning them the task, resulting in the potential for complications related to obstetrical (maternal/child) care to go unrecognized and untreated (A397);

2. Nurses assigned to triage patients in the Emergency Department (ED) demonstrated competence in determining the patient's severity of illness or injury prior to assigning them the task, resulting in the potential for ED patients requiring rapid or immediate care to experience prolonged wait times (A397); and,

3. Nurses on the rapid response team (RRT - a team that responds to emergencies throughout the facility to assist in stabilizing a patient and preventing cardiac and/or respiratory arrest) demonstrated competence in appropriately caring for the patient based on the reason for the RRT call (a standardized procedure) prior to assigning them to the team, resulting in the potential for inpatients with declining health and medical emergencies to be treated incorrectly (A397).

The cumulative effect of these systemic problems resulted in failure to ensure nursing care was being provided throughout the facility in a safe and effective manner.
VIOLATION: PATIENT CARE ASSIGMENTS Tag No: A0397
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to ensure:

1. Seven of seven Obstetrical (OB) nurses (OB RN 1, OB RN 2, OB RN 3, OB RN 4, OB RN 5, OB RN 6, and OB RN 7), demonstrated competence in performing an obstetrical evaluation;

2. Nurses assigned to triage patients in the Emergency Department (ED) demonstrated competence in determining the patient's severity of illness or injury prior to assigning them the task; and,

3. Nurses on the rapid response team (RRT - a team that responds to emergencies throughout the facility to assist in stabilizing a patient and preventing cardiac and/or respiratory arrest) demonstrated competence in appropriately caring for the patient based on the reason for the RRT call (a standardized procedure), prior to assigning them to the team.

These failed practices resulted in the potential for complications related to obstetrical (maternal/child) care to go unrecognized and untreated, ED patients requiring rapid or immediate care to experience prolonged wait times, inpatients with declining health and medical emergencies to be treated incorrectly, and the potential for harm or death in patients throughout the facility.

Findings:

The facility policy titled, "Staffing Plan," was reviewed on August 2, 2016. The policy indicated staff assigned to any area would be assigned only to those tasks for which they had demonstrated competency.

1. During the entrance conference with facility staff, on August 1, 2016, at 10:15 a.m., the Chief Nursing Officer (CNO), who was also the Interim Manager of Maternal Child Health (IMMCH), indicated the facility's volume for deliveries last year was 243.

On August 1, 2016 at 11 a.m., a tour of the Labor and Delivery Unit was conducted. There were two delivery rooms and three labor rooms.

On August 1, 2016, at 11:40 a.m., during an interview with OB RN 2, the nurse stated when a pregnant patient entered the Labor and Delivery area, the physician was contacted and the patient underwent external fetal monitoring (EFM-external monitoring of fetal heart rate to assess fetal well-being, before and during labor) and an obstetrical assessment by the RN.

OB RN 2 stated if the patient was not in labor, the patient's physician was contacted and a report of the patient's condition was provided. OB RN 2 stated a patient could be discharged upon a physician's telephone order.

On August 2, 2016, Patient 15's record was reviewed. Patient 15 presented on July 30, 2016, at 11:34 p.m., with complaints of lower abdominal pain and pressure. According to the "Clinical Notes," Patient 15 was 26 weeks (six months- preterm) pregnant and had a history of previous surgical delivery (cesarean section). OB RN 3 documented the patient's assessment and called the patient's physician for, "report and orders."

Physician orders, at 11:42 p.m., included laboratory tests, a biophysical profile (non invasive-ultrasound test to evaluate fetal well being), fetal monitoring and intravenous fluids (directly into the vein). On July 31, 2016, at 6:54 a.m., a phone order indicated "May discharge patient after breakfast if no complaint of pain."

There was no documentation in the physician progress notes to indicate Patient 15's physician saw the patient prior to her discharge.

On August 2, 2016, at 11 a.m., OB RN 4 was interviewed. OB RN 4 stated when a pregnant patient came to the Labor and Delivery Unit, a triage assessment was conducted. OB RN 4 stated there was no annual competency evaluation for performing the triage assessment.

The employee file for OB RN 2 was reviewed on August 3, 2016. There was no current evidence in OB RN 2's personnel file indicating competency in performing an obstetrical assessment was validated by the department director or a physician.

The personnel file for OB RN 3 was reviewed. (OB RN 3 performed the obstetrical assessment on Patient 15 on July 30, 2016) There was no evidence in the personnel file OB RN 3's competency in performing an obstetrical assessment was validated by the department director or a physician.

The personnel files for the remaining labor room staff were reviewed with the DE. There was no evidence in the personnel files for OB RN 1, OB RN 4, OB RN 5, OB RN 6, and OB RN 7 that competence in performing an obstetrical assessment was validated.

On August 3, 2016, at 1:30 p.m., during an interview with the Director of Education (DE), the DE stated there were six full time Labor and Delivery nurses who could perform obstetrical assessments. After reviewing OB RN 2's file, the DE stated there was no current OB competency assessment completed for any of the OB nurses.

The policy and procedure regarding obstetrical assessment, last reviewed on August 2015, was reviewed. The policy indicated the facility provided staff that was qualified to determine "if a pregnant patient is obstetrically stable to be discharged or if an emergency condition exists and the patient must be admitted to the hospital for further care....The examination must be conducted by an individual who is determined qualified by hospital bylaws or rules and regulations..."

The policy indicated all pregnant patients over 20 weeks gestation would be evaluated by a physician with admitting privileges, or an RN qualified to perform an obstetrical exam, prior to discharge from the Labor and Delivery Unit. The policy further indicated prior to discharge from the Labor and Delivery Unit, the RN would notify the physician of the assessment findings, and would obtain a physician's order for discharge.

Education and training requirements included: "The RNs' annual performance review will include documentation of continued competence as validated by the Director of Maternal Child Health with input from the Chairman of the Maternal Child Health Committee and/or physicians who admit patients to the unit."

2. During an interview with the ED Director (EDD) on August 2, 2016, at 11:05 a.m., the EDD stated the nurses triaged patients presenting to the ED for care according to the Emergency Severity Index (ESI) tool.

The ESI is a five-level tool for use in emergency department (ED) triage. According to the Agency for Healthcare Research and Quality (AHRQ), ED nurses use the ESI to rate patient acuity (severity), from level 1 (most emergent) to level 5 (least resource intensive). Levels 1 and 2 are assigned due to the acuity of the patient. Levels 3, 4, and 5 are assigned based on the amount of resources that are/will be required to appropriately diagnose and treat the patient. The ESI levels are assigned as follows:

Level 1 - Requires immediate life saving intervention;

Level 2 - High risk patient with altered level of consciousness, severe pain or distress, or dangerous vital signs (heart rate or respiratory rate too high, or oxygen level too low);

Level 3 - Multiple resources required (labs, EKG, intravenous line, simple procedures [i.e. sutures], x-ray, consults, medication administration [other than oral]). Vital signs are not in the danger zone (for pediatric patients 3 months to 3 years of age, ESI 3 should be considered if the temperature is above 102.2);

Level 4 - One resource required, vital signs are not in the danger zone; and,

Level 5 - No resources required, vital signs are not in the danger zone.

The facility policy titled, "Triage/Admission to the Emergency Department," was reviewed on August 2, 2016. According to the policy, all patients presenting to the ED would be assessed and prioritized using a five level triage system. The triage levels were to be assigned as follows:

Level 1 - Resuscitation;

Level 2 - Emergent (any patient whose condition could be expected to worsen if not quickly treated, or severe pain of 8 or greater);

Level 3 - Urgent (Requiring prompt care, but condition is not expected to worsen, or pain of 4 to 7). (Not consistent with the ESI definition of Level 3);

Level 4 - Nonurgent (Minor trauma or single system complaint with normal vital signs, and no respiratory component). (Not consistent with the ESI definition of Level 4); and,

Level 5 - Minor (Patients with minor or chronic complaints). (Not consistent with the ESI definition of Level 5).

Patients are assigned directly to beds for treatment or sent to the lobby to wait depending on their assigned ESI level. An ESI level 1 or 2 goes directly to a bed, while an ESI level 3, 4, or 5 can wait in the lobby for examination and treatment to be done at a later time. The higher the ESI level assigned (level 5 vs. level 4 or 3), the longer the patient can wait to be examined and treated.

Review of triage records with the EDD on August 2, 2016 (for patients currently in the ED), revealed the following:

a. Patient 34, a [AGE] year old female, was brought in by ambulance at 10:50 a.m., with a complaint of knee pain after falling, and a pain level of 10/10.

The triage nurse (ED RN 2) assessed the patient and assigned her an ESI level 4:

- One resource required according to the ESI tool. The level was not appropriate according to the AHRQ ESI rating as the patient would likely require more than one resource (indicating she was a level 3); and,

- Nonurgent with pain level less than 4 according to the hospital policy. The level was not appropriate, as the patient had a pain level of 10/10 (indicating she was an ESI level 2 or 3).

The record indicated Patient 34 had x-rays of her hip, femur (long leg bone), knee, ankle, and foot. In addition, she required one oral pain medication and one pain medication given by injection to control her pain.

During a concurrent interview with the EDD, he stated the ESI level should have been a 3 due to the pain level and the resources that would be required to care for the patient.

b. Patient 35, a [AGE] year old female, was brought in by ambulance at 9:02 a.m., with a complaint of abdominal pain at a level of 5/10.

The triage nurse (ED RN 2) assessed the patient and assigned her an ESI level 4:

- One resource required according to the ESI tool. The level was not appropriate, according to the AHRQ ESI rating, as the patient would likely require multiple resources (indicating she was an ESI level 3); and,

- Nonurgent with pain level less than 4 according to the hospital policy. The level was not appropriate, as the pain level was 5/10 (indicating she was an ESI level 3).

The record indicated Patient 35 had an IV started, multiple labs drawn, urine tests, IV fluids for hydration, IV medications to treat nausea, oral medications to treat the abdominal pain, an x-ray, and an ultrasound.

During a concurrent interview with the EDD, he stated the ESI level should have been a 3 due to the patient's pain level and the resources that would be required to care for the patient.

c. Patient 36, a one year old male, was brought in by family at 10:57 a.m., with complaints of fever and pulling at his ear.

The triage nurse (ED RN 2) assessed the child, whose vital signs included a temperature of 103.1 Fahrenheit (normal 98.6) and a heart rate of 144 (normal 80-130), and assigned him an ESI level 5:

- No resources required for ESI Level 5 according to the ESI tool. According to the AHRQ ESI rating, the level was not appropriate, as Patient 36 would likely require medications (at least one resource - indicating he was an ESI level 3); and,

- Minor severity with normal vital signs according to the hospital policy. The level was not appropriate, as he had a significant fever and an elevated heart rate (indicating he was an ESI level 3).

During a concurrent interview with the EDD, he stated the ESI level should have been a 3 due to the temperature of 103.1 Fahrenheit.

The files for ED RN 1, 2, and 3 were reviewed on August 3, 2016. There was no evidence in the file the nurses had demonstrated competency in triaging patients or using the ESI tool.

During an interview with the EDD on August 2, 2016, at 11:50 a.m., the EDD stated no education had been done for nurses working in the ED to learn the ESI level assignment system. He stated none of the ED nurses had been assessed for or demonstrated competency in assigning appropriate ESI levels. He stated he did not do any monitoring of the assignment of ESI levels to determine whether they were being assigned appropriately.

3. During an interview with the EDD on August 3, 2016, at 3:40 p.m., the EDD stated one ED nurse was assigned to the RRT each shift. He stated the assignment rotated, and any ED nurse could be assigned to the team at any time. The EDD stated there was a backpack in the ED that the RRT nurse took with them when a RRT was called. According to the EDD, the protocol allowing the nurses to treat the patient in the absence of a physician was included in the backpack.

The facility document titled, "Rapid Response Team Event Summary," was reviewed with the EDD on August 3, 2016. The document included interventions that could be performed in the absence of a physician based on the symptoms the patient was demonstrating and the assessment made by the RRT nurse.

The facility policy titled, "Rapid Response Team," was reviewed with the EDD on August 3, 2016. The policy indicated a RRT consisting of a Registered Nurse (RN), a Respiratory Therapist (RT), and an Administrative Supervisor would respond immediately to requests for patient assessment to facilitate treatment of a patient who displayed signs of deterioration. The policy indicated the ED RN would be the team leader, and the team would assess the patient's condition and order tests and/or treatment utilizing the standardized protocols.

The files for ED RN 1, 2, and 3 were reviewed on August 3, 2016. There was no evidence in the file the nurses had demonstrated competency in leading the RRT.

During a concurrent interview with the EDD, he stated none of the ED nurses who were assigned to (lead) the RRT had been assessed for, or demonstrated, competency in the procedure prior to being assigned to lead the team.