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.

SOUTHWEST HEALTHCARE SYSTEM 25500 MEDICAL CENTER DRIVE MURRIETA, CA 92562 June 1, 2012
VIOLATION: GOVERNING BODY Tag No: A0043
The hospital must have an effective governing body legally responsible for the conduct of the hospital as an institution. If a hospital does not have an organized governing body, the persons legally responsible for the conduct of the hospital must carry out the functions specified in this part that pertain to the governing body.

This Condition is not met as evidenced by:
Based on observation, interview, and record review, the hospital failed to ensure the governing body carried out its full and complete oversight for the hospital as a whole by failing:

1. To comply with the requirements of ?482.55 (A 1100) by failing to meet the emergency needs of patients with obstetrical-related complaints at Campus 1 ED (Emergency Department), in accordance with the facility's established process (Refer to A92; A1100).

2. To ensure the ED RN conducted an accurate nursing assessment and evaluation (Refer to A395) ; and
3. To ensure fetal assessment/re -assessment, to include fetal heart tones (FHTs) was completed for all OB patients 20 weeks or above and failing to ensure the Labor and Delivery (l&D) nurse was called immediately according to the facility's established process (algorithm) for OB patients 20 weeks or above EGA (Estimated Gestational Age; fetus' age in weeks) (Refer to A395; A1100; A1103);

4. To ensure an informed consent was obtained prior to an interfacility transfer (refer to A395);

The cumulative effect of these systemic problems resulted in failure of the governing body to ensure patients were receiving quality care in a safe and effective manner.
VIOLATION: EMERGENCY SERVICES Tag No: A0092
If emergency services are provided at the hospital, the hospital must comply with the requirements of ?482.55.

This Standard is not met as evidenced by: Based on observation, interview, and record review, the facility failed to comply with the requirements of ?482.55 (A 1100) by failing to meet the emergency needs of patients with obstetrica l-related complaints at Campus 1 ED (Emergency Department) for 2 of 5 emergency obstetrical cases reviewed (Patients 10 and 24), in accordance with the facility's established process (Refer to A 1100).

Background: The facility has two campuses, both with an ED. On December 16, 2011, Campus 1's Labor and Delivery Department, which provided services for Obstetrical (OB) emergencies was closed and integrated with Campus 2's Women's Services. Since then, any pregnant patient presenting themselves to Campus 1's ED had to be evaluated within the capabilities of the ED.

Findings:

The facility failed to meet the emergency needs of patients with obstetrical-related complaints at Campus 1 ED (Emergency Department), in accordance with the facility's established process by failing to:

a. Ensure fetal assessment/re-assessment ,to include fetal heart tones (FHTs) was completed for all OB patients 20 weeks or above (Refer to A1103);

b. Ensure the Labor and Delivery (L&D) nurse was called immediately according to the facility's established process (algorithm) for OB patients 20 weeks or above EGA (Estimated Gestational
Age; fetus' age in weeks) (Refer to A 1103; A395) ;

c. Ensure OB patients 20 weeks or above EGA, including the fetus' status, were assessed and monitored, and not sent back in the waiting room, without direct supervision (Refer to A 1103; A395) ; and

d. Establish an accurate Estimated Gestational Age, which determined how the patient and fetus were going to be treated and cared for (Refer to A 1103; A395).

(Refer to A 1100)

On June 1, 2012, at 10:50 a.m.. members of the Governing Body (GB) were interviewed. The GB members were aware of the closure of the OB services located at Campus 1 and that OB services would be integrated at Campus 2 that occurred on December 16, 2011. The GB members were not aware of any concerns in providing emergency services for OB patients at Campus 1 ED after the transition of services. The GB members were not aware that the established process (algorithm) was not being appropriately implemented.
VIOLATION: PATIENT RIGHTS: INFORMED CONSENT Tag No: A0131
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care.

The patient's rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate.

This Standard is not met as evidenced by: Based on interview and record review, the facility failed to ensure an informed consent was obtained prior to an interfacility transfer for one of 32 sampled patients, (Patient 30). This failure
could result in the lack of patient involvement with her medical treatment.

Findings:

A review of Patient 30's record was conducted on May 31, 2012. Patient 30 was admitted to the facility on on [DATE], with pyelonephritis (inflammation and/or infection of the kidney) . On May 25, 2012, the patient's physician wrote an order to transfer the patient to another facility for further diagnostic testing.

Further record review failed to show that either an oral or written consent was obtained from the patient prior to transfer via ambulance on May 25, 2012, at 5:45 p.m.

An interview was conducted with the Registered Nurse (RN 8) on May 31, 2012, at 9 a.m., who stated there was not a consent in Patient 30's record to indicate the patient agreed to be transferred .

A review of the facility policy, "Transfer/Transport of Patients: Between Patient Care Units and/or Between Campuses (Reviewed 10/27/11)," was conducted. The process indicated, "Obtain patient consent for transfer/transport ...lf the transport is for diagnostic or medicaltreatment at the opposite campus, the medical provider, RN (registered nurse) or Charge Nurse/Supervisor informs the patient of the need for transport via ambulance. If patient agrees obtain consent."
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
The hospital must measure, analyze, and track quality indicators, including adverse patient events, and other aspects of performance that assess processes of care, hospital services and operations.

This Standard is not met as evidenced by: Based on interview and record review, the facility failed to identify and track aspects of performance of the emergency care, services,
and operation to obstetrical (OB) patients seen in the Campus 1 ED, after the closure of Campus 1's Labor and Delivery (L&D) unit. This failure had resulted in missed opportunities to identify and investigate processes of care, and identify opportunities for improvement within the hospital's operation.
Findings:
Background: The facility has two campuses, both with an ED. On December 16, 2011, Campus 1's Labor and Delivery Department, which provided services for Obstetrical (OB) emergencies was closed and integrated with Campus 2's Women's Services. Since then. any pregnant patient presenting themselves to Campus 1's ED had to be evaluated within the capabilities of the ED.

(Refer to A385 ; A395 ; A 1100; and A 1103)

On June 1, 2012, at 10:03 am, the survey team met with the members of the facility's quanity
team. The Performance Measurement Director (PMD) stated since the facility closed the OB services at Campus 1, the focus of Performance improvement projects included. Campus 2's womens Services volume shift timely initiation of prcesses, conducting the MSE timely, and consolidation of OB staff

During the interview, the Director of Women's Services (DWS) and Director of Emergency Services (DES) stated additional steps were also taken prior to the closure of the Campus 1's L&D unit. This included communication provided to outlying OB clinics and physician's offices of the unit's closure. In addition, once the L&D closed on December 16, 2011, L&D nurses were assigned to Campus 1's ED for two weeks in order to ensure the ED RNs provided services to OB patients in accordance with the facility's established process.

During the interview, the PMD stated the facility had not initiated any tracking or collection of data related to the newly established process (specifically related to the algorithm) in Campus 1's ED, with regards to providing services for OB patients 20 weeks or above with OB-related complaints since the closure of the L&D unit. The PMD stated the facility has not had any identified concerns or issues related to the care of these patients.
VIOLATION: NURSING SERVICES Tag No: A0385
The hospital must have an organized nursing service that provides 24-hour nursing services. The nursing services must be furnished or supervised by a registered nurse.

This Condition is not met as evidenced by: Based on observation, interview,and record review, the facility failed to ensure that nursing services met the needs of the patients by failing :

1. To ensure the ED RN conducted an accurate nursing assessment and evaluation and failed to ensure the ED staff obtained fetal heart tones (FHTs) according to the facility's process (algorithm) and assess fetal well being for 2 of 5 OB patients reviewed. (Refer to A395) ;

2. To enswe the Labor and Delivery (L& D) nurse was called immediately according to the facility's established process (algorithm) for 2 of 5 OB patients reviewed. (Refer to A395);

3. To ensure an OB patient, was assessed and monitored, including fetal status,and the OB patient was not sent back to the waiting room without direct supervision for 2 of 5 OB patients reviewed (Refer to A395);

4. Establish an accurate Estimated Gestational Age (EGA), which determined how the patient and fetus were going to be treated and cared for 1 of 5 OB patients reviewed (Refer to A395);

5. To ensure an informed consent was obtained prior to an interfacility transfer for 1 of 32 sampled
patients (refer to A395) ;

6. To develop an individualized plan of care for discharge planning when the patient was assessed to need skilled nursing services upon discharge for 1 of 32 sampled patients (Refer to A396);

7. To ensure a Physician's order to administer Potassium, (Potassium is an essential mineral necessary for functioning of the heart, nerves, and muscles) was implemented for 1 of 32 sampled patients(Refer to A405 );

9. To ensure physician pain medication orders were correctly transcribed and administered as ordered by the physician for 1of 32 sampled patients(Refer to A405 ); and

10. To ensure the physician order for Levophed (medication to increase blood pressure) was administered as ordered, or an order indicating to hold the medication was obtained from the physician for 1 of 32 sampled patients (Refer to A405 ).

The cumulative effect of these systemic problems resulted in failure to ensure the provision of quality nursing services.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

A registered nurse must supervise and evaluate the nursing care for each patient.
This Standard is not met as evidenced by:
Based on observation, interview, and record review, the facility failed to ensure that the
nursing service evaluated the care of each patient by failing:

1. To ensure the ED RN conducted an accurate nursing assessment and evaluation of Patient 10, when fetal heart tones (FHTs) were not obtained and the Labor and Delivery (L& D) nurse was not called immediately according to the facility's established process (algorithm), and based on
the facility's determination of Patient 10 being seven months pregnant. Nursing service also failed to monitor Patient 10 when she was sent back to the waiting room without direct supervision.

This resulted in a delay in care and the possible delivery of a premature infant (infant born before the 37th week of pregnancy).

2. To ensure the ED RN conducted an accurate nursing assessment and evaluation of Patient 24, when fetal heart tones were not obtained and the Labor and Delivery (L&D) nurse was called immediately according to the facility's established process (algorithm), based on the facility's initial determination of the patient's Estimated Gestational Age of 27 weeks (EGA; fetal age in weeks). Nursing service also failed to ensure the patient, including the fetal status (initially determined to have an EGA of 27 weeks) was assessed and monitored, and not sent back to the waiting room without direct supervision. Nursing service failed to establish an accurate EGA, which determined how the patient and fetus were going to be treated and cared for.

3. To ensure an informed consent was obtained prior to an inter-facility transfer for one of 32 sampled patients, (Patient 30). This failure could have resulted in the lack of patient involvement with her medical treatment.

Findings:

Background:The facility has two campuses , both with an ED. On December 16, 2011, Campus 1's Labor and Delivery Department, which provided services for Obstetrical (OB) emergencies was closed and integrated with Campus 2's Women's Services. Since then, any pregnant patient presenting themselves to Campus 1's ED had to be evaluated within the capabilities of the ED.

1. On May 30, 2012, the record for Patient 10 was reviewed. Patient 10 presented on May 29, 2012, at 9:07 p.m. The "ER (emergency room ) Demographics" revealed Patient 10 was complaining of "back/abdominal cramping after being hit in the stomach - 7 months pregnant." The "Emergency Record" dated May 29, 2012, revealed:

a. At 9:07 p.m., Patient 10 was "GREETED" by RN 21 and was placed in the waiting room on "BED WAIT."
b. At 9:40 p.m., RN 21 "triaged" Patient 10 and determined she was "29 and 5 days pregnant, with lower abdominal pain with cramping."
c. At 10:54 p.m., the Physician's Assistant (PA) 3 initiated the medical screening examination for Patient 10 and "Per customary practice initial diagnostic studies ordered at this time to expedite patients care. Capacity issues have prevented immediate bedding. Patient is stable for the waiting room, informed of plan and advised to alert the greeter RN for any change of condition."
No FHTs were obtained , and laboratory tests specific to Patient 1O's chief complaint of abdominal trauma and cramping/preterm labor were not ordered.

There was no documentation in the record as to when the OB nurse was called to respond to the Campus 1 ED to evaluate Patient 10.

The Campus 1 "Emergency Department Algorithm for OB Patients" dated Apr il 19, 2012, revealed "Pt (patient) is seen by provider who performs MSE (medical screening examination) ED RN obtains Fetal Heart Tones" and if the patient had an OB related complaint, the ED Charge Nurse would "immediately" call the OB Charge Nurse at Campus 2 who assigned a L&D RN from Campus 2 to respond to the Campus 1's ED.

The "OB Outpatient Record" dated May 30, 2012, was initiated by the OB nurse at 12:07 a.m. Patient 10 was placed on an external fetal monitor, and at 12:15 a.m., the baseline FHTs were 130, with moderate variability (the ability of the fetal heart to respond to external stimuli through a well balanced nervous system) and there was positive fetal movement. The obstetrical physician was called at 12:30 a.m. The "Outpatient Observation Orders" dated May 30, 2012 , at 12:45 a.m., revealed laboratory tests were ordered to include a fetal fibronectin (helps predict preterm delivery), and a Kleihauer-Betke (detects and measures the number of fetal cells in the mother's blood. This test is used to predict certain types of pregnancy complications, particularly after a mother has suffered a traumatic injury.) In addition, medication was ordered to stop Patient 1O's contractions. On May 30, 2012, at 3:45 a.m., Patient 10 was transported via ambulance to the Labor & Delivery unit at Campus 2.
On May 31, 2012, at 9:30 a.m., a tour of the Campus 1 ED was conducted .

During an interview with the Campus 1 ED Charge Nurse (RN 13), on May 31, 2012, at 9:45
a.m., she stated all patients greater than 20 weeks gestation "get FHTs," and if the patient presented with a pregnancy related complaint, she would initiate the L&D nurse coming over from Campus 2 to the Campus 1 ED. RN 13 stated they were "supposed to put in the record when the OB nurse was called and when the OB nurse arrived" at the Campus 1 ED. In addition, RN 13 stated she would not place the patient back in the waiting room.

During an interview with the Director Emergency Services (DES) on May 31, 2012, at 11:40 a.m., she reviewed the record and was unable to find documentation of FHTs until three hours after Patient 10 arrived at the Campus 1 ED, and when the Campus 2 OB nurse was called to respond to the Campus 1 ED. In addition, the DES stated Patient 10 should have had a fetal assessment to include FHTs and should not have been placed in the waiting room.

During a telephone interview with RN 21, on May 31, 2012, at 2:05 p.m., she stated she "GREETED (first encounter with an RN for an ED patient)" Patient 10, assigned her an Emergency Severity Index Level 3 [patients requiring two or more resources, done on a Level 1 (most ill patients) through Level 5 scale], and had Patient 10 return to the waiting room. RN 21 stated she gave the "paper work" to the Treatment & Procedure Nurse and she called the ED Charge Nurse to tell her there was a pregnant patient greater than 20 weeks gestation in the ED waiting room. In addition, RN 21 stated the ED was busy so she later "triaged" Patient 10 for the Treatment & Procedure Nurse at the "GREET" desk, and she could not obtain the FHTs because she could not provide privacy for Patient 10 at the "GREET" desk. RN 21 stated when she was the Treatment & Procedure Nurse,she always obtained the FHTs.

2. The facility's document titled, "[Campus 1's name] Emergency Department Algorithm for OB Patients" revised April 19, 2012, was reviewed. The document indicated:

- When pregnant patients (20 weeks and above EGA) presented to the ED, the patient needed to be seen by the provider who performed a MSE and the ED RN obtained Fetal Heart Tones (FHTs); and

- When a patient was in "apparent or suspected labor or need fetal monitoring," the ED Charge Nurse called the OB charge nurse at Campus 2 immediately and assigned a L&D RN to respond to Campus 1's ED...Assigns primary ED RN...ED Unit Secretary immediately calls (Ambulance Company's name) to notify them of either transport STAT or possibility of transport.

On May 30, 2012, Patient 24's record was reviewed. The patient presented to Campus 1's ED on May 9, 2012, at 12:28 a.m. with chief complaints of stomach cramps and 5 months pregnant.
The "Imaging Patient Pregnancy Questionnaire (Age 12 to 55 years)," was filled out upon arrival in the ED. The document indicated Patient 24 was pregnant, with the first date of her last menstrual period (LMP - used to determine the EGA) being January 13, 2012.

The "Emergency Record" indicated the patient triaged (process to determine the priority of complaint) on May 9, 2012, at 12:42 a.m. The record indicated the patient's complaint as, "5 Months pregnant cramping...on and off lower abd(omen) cramping since 4 hrs (hours) ago..." The record did not contain documented evidence fetal heart tones were obtained or an attempt was made to obtain them.

The "HPI(History of Present Illness) Abdominal Pain" conducted by the practitioner (Physician Assistant [PA] 3) on May 9, 2012, at 1:01 a.m., indicated,"Patient presents for evaluation of abdominal pain...onset 1 hour ago...associated with loss of appetite and nausea...Patient with lower abdominal pain 27 weeks with cramping sip (status post) fall today. No vaginal bleeding or discharge." There was no documented evidence the fetal condition was assessed.

On May 31, 2012, at 3:20 p.m., RN 5 {the triage nurse for Patient 24) was interviewed by phone. RN 5 was unable to recall the situation with Patient 24. RN 5 stated the facility's practice was when a pregnant patient came to the ED, the patient was immediately brought in the RME area for evaluation. Once the pregnant patient was identified to be 20 weeks or above, the L&D
nurse (from Campus 2) was called to come in to care for the patient.

The "Orders" dated May 9, 2012, at 12:57 a.m., included,"Call L&D Nurse for clearance." The
record did not contain documented evidence the L&D nurse was called.

On May 31, 2012, at 10:50 a.m., RN 6 (L&D RN in Campus 2's Women's Services) was interviewed. RN 6 stated Campus 1's ED would call their department when a RN needed to go to Campus 1's ED for a pregnant patient 20 weeks and above, with OB related complaints. When it was determined a L&D nurse needed to be sent to Campus 1 ED, the expectation was the nurse should arrive within 30 minutes. The L&D nurse would sign out in the log to indicate the time of departure from the Women's Services unit (located in Campus 2). She stated if a patient was
less than 20 weeks pregnant, the nurse would not be sent according to the facility policy. During the interv iew with RN 6, the DWS (Director of Women's Services) and L&D Manager (LDM) were present and agreed that the L&D nurse should be at Campus 1's ED within 30 minutes when required to be there.

On May 31, 2012, at 9:30 a.m., RN 13 (Campus 1's ED RN) was interviewed. She stated if a pregnant patient (20 weeks or above) presented in the ED, the patient was immediately placed in
the RME area, the L&D nurse was called immediately,and was expected to get to the ED within 30 minutes.

The facility document titled, "Daily Float Hours to [Campus 1's name] ED" was reviewed. The log indicated RN 12 signed out at 1:45 a.m. (approximately 1 hour and 17 minutes after Patient 24 presented herself In the ED and 48 minutes after PA 3 ordered the L&D nurse to be called).
The "Emergency Record" indicated the L&D RN (RN 12) was at Patient 24's bedside on May 9, 2012, at 2:10 a.m. (approximately 1 hour and 43 minutes after Patient 24 presented herself in the ED and 1 hour and 13 minutes after PA 3 ordered the L&D nurse to be called).

On May 31, 2012, at, 2:35 p.m., a phone interview was conducted with RN 12 (L&D nurse that was sent to Campus 1's ED for Patient 24).
RN 12 stated Campus 2's Women's Services received a call from Campus 1's ED requesting to have a L&D care for Patient 24's OB concerns.
RN 12 stated she received preliminary information that Patient 24's EGA was 23 or 27 weeks and the patient was having abdominal pain.

The "Doctor Notes" documented by PA 3 on May 9, 2012, at 1:01 a.m., indicated, "...MSE (Medical Screening Exam) initiated in RME [Rapid Medical Exam - also known as TAP (Treatment and Procedure) area]...Capacity issues have prevented immediate bedding. Patient is stable
for waiting room, informed of plan and advised to alert the greeter RN for any change of condition..." There was no documented evidence the fetalcondition was assessed.

The "Orders" dated May 9, 2012, at 12:57 a.m., included, "Call L&D Nurse for clearance."

A request was made for a policy and procedure which indicated the Campus 1 ED's process for pregnant patients who presented themselves to the ED. The facility did not have specific policies addressing Campus 1's process considering the campus no longer had the Labor and Delivery unit available.
The facility policy titled, "Triage: Five Level (Emergency Department Specific)" dated April 2011, indicated, "Pregnant Patients Only:

Pregnant women (greater than 20 weeks gestation) may be triaged out of the Emergency Department to the Women's Center;

Pregnant women stable for immediate transport to the Labor & Delivery unit do not need to be registered or triaged in the emergency department;

Pregnant women will be transported directly to Labor & Delivery by hospital personnel on a stretcher or wheelchair; and

If there is no pregnancy-related complaint, if the patient is unstable, or if the triage RN is unsure of appropr iateness of transport to Labor & Delivery, a quick triage will be completed and the provider will clear the patient for transport or full triage and registration in the ED."

On May 31, 2012, at 9:20 a.m., RN 14 (assigned as the "greeter/first patient contact" in the ED) was interviewed and stated if a patient presented to the ED and was identified as pregnant, information required to have was the date of their LMP. The computer automatically computed the patient's EGA RN 14 stated it was significant to determine the patient's EGA to determine the nature and level of urgency to treat the patient with their chief complaint related to why the patient was being seen in the ED. If a patient was more than 20 weeks with the EGA, the Campus 2 - Women's Services' charge nurse was immediately called to send a L&D nurse to Campus 1 ED.

On May 31, 2012, at 9:30 a.m., RN 13 (Campus 1's ED RN) was interviewed. She stated if a pregnant patient (20 weeks or above) presented to the ED, the patient was immediately placed in the RME area, the L&D nurse was called immediately and was expected to get to the ED within 30 minutes. RN 13 stated the patient's EGA was determined by inputting in the computer system the patient's LMP, and it will automatically indicate the patient's EGA RN 13 stated the EGA was determined to identify the type of treatment and response the patient needed.

The facility policy titled, "Bed Placement: Obstetrical Patient (Women's Services Specific)" dated Apr il 2011, was reviewed and indicated, "The labor and delivery Charge Nurse or designee determines appropriate placement of the patient; As obstetrical beds become limited the Charge Nurse/designee will triage by acuity; Patients unable to be placed in a patient room at the time they present to the unit will be evaluated by the charge nurse or designee, completing the OB intake form to determine acuity according to the patient's responses...Fetal Movement...Contractions (frequency, strength and duration)...; and Patients not assigned to an obstetrical bed will be reassessed every thirty minutes or promptly upon patient report of status change. Information will be documented in the patient's medical record..."

On May 31, 2012, at 11:05 a. m., Patient 24's record was reviewed with the DES, DWS, and LDM. The DES stated the record indicated the patient was considered as having an EGA of 27 weeks. The DES was unable to find documented evidence the ED staff attempted to obtain the patient's FHTs or whether they were unobtainable. The DES and DWS stated Patient 24's FHT should have been obtained or if unobtainable should have documented as such. Both were not able to find a complete obstetr ical assessment that included an accurate determination of the patient's EGA (actually 16 517 weeks) and the fetal condition.

On May 31, 2012, at 1:45 p.m., Patient 24's record was further reviewed with the DES, DWS, and LDM. The DES stated, with the patient being identified as having an EGA of more than 20 weeks, there was a delay in getting the L&D nurse to Campus 1's ED.

In the same interview, the DES stated in a "hindsight" review of Patient 24's record, she stated the patient should not have been placed back in the waiting room.

3. A review of Patient 30's record was conducted. Patient 30 was admitted to the facility on on [DATE], with a diagnosis of pyelonephritis (inflammation and/or infection of the kidney). On May 25, 2012, the patient's physician wrote an order to transfer the patient to a sister facility for further diagnostic testing.

Patient 30 was transferred to the sister facility via ambulance on May 25, 2012, at 5:45 p.m. There was no documentat ion found which reflected the precise time Patient 30 arrived at the accepting facility and the time the patient was placed in a room.

Patient 30's initialassessment as documented in the "Nursing Progress Notes Continuation Sheet," by the accepting facility was completed on May 25, 2012, at 8 p.m., two hours and fifteen
minutes after leaving the transferring facility , which is located 5.9 miles from the accepting facility.

A review of the facility policy, "Assessment I Reassessment Of Patient (Revised: 8/2011)," was conducted. The policy indicated, "Area assessment must be documented at the time of transfer by the accepting nurse. This reassessment must include, but is not limited to, a general impression of the patient with a focused system specific assessment of those problems identified on the care plan and/or identified problems on the patient's presentation to the accepting nurse."

An interview was conducted with the Registered Nurse (RN 7) on May 29, 2012, at 10:15 a.m. RN 7 stated when a patient is transferred between the sister facilities an assessment is to be done upon arrival, which includes a full body assessment, from head to toe.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient. This Standard is not met as evidenced by:
Based on interview and record review, the facility failed to develop an individualized plan of care for discharge planning when the patient was assessed to need skilled nursing services upon discharge for one of 32 sampled patients (Patient 16). This had the potential to result in Patient 16 not being prepared for discharge.
Findings:
On May 29, 2012, the record for Patient 16 was reviewed. Patient 16 was admitted to the facility on on [DATE] , with diagnoses including total left knee replacement.
The "Discharge Planning/Social Services Needs Assessment" was done by the Health Maintenance Organization (HMO) case manager on May 25, 2012, and revealed Patient 16 would need short term rehabilitation placement upon discharge. The next discharge planning note was documented on May 28, 2012, at 11:30 a.m., and revealed "Order to discharge to rehab (rehabilitation)/snf (Skilled Nursing Facility) if echo (ultrasound of the heart) results are normal."
The "Interdisciplinary Plan of Care" with a start date of May 21,2012, revealed the "Alteration in Care ManagemenVHousing/Functional Mobility - Related to: Need for alternate level of care" was blank and had not been initiated.
During an interview with the Care Coordination Manager (CCM), on May 29, 2012, at 3:15 p.m.. she reviewed the record and was unable to find documentation of an individualized plan of care for discharge planning for Patient 16. The CCM stated there should have been a care plan developed. In addition, the CCM stated she would prefer that the facility care coordinators complete the initial needs assessment for the patients but it was not a requirement and the HMO case managers could complete the initial assessment.
The facility policy and procedure titled "Discharge Planning" reviewed April 2011, revealed "... If any of the above risk factors are identified on the initial discharge screen a needs assessment will be done within 2 days by Care Coordination/Social Worker.All initial Discharge Planning Needs Assessment addresses the following: ... If risks or post-discharge needs are identified the Care Coordinator/SocialWorker will make an entry on the "Individualized Plan of Care" (IPOC) with a target date for follow-up.This entry in location under category of "Alteration in Care Management/Housing/Functional Mobility..."
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient's care as specified under ?482.12(c), and accepted standards of practice.

(1) - All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures.

This Standard is not met as evidenced by: Based on interview and record review, the facility failed.

1. To ensure a Physician's order to administer Potassium, (Potassium is an essential mineral necessary for functioning of the heart, nerves, and muscles) was implemented "NOW" (within one hour from the time the order is written) for one of 32 patients, (Patient 28). This failure led to a 45 minute delay in the administration of Potassium for Patient 28 who had a critically low Potassium level potentially impacting the patient's medical status;

2. To ensure physician pain medication orders were correctly transcribed and administered as ordered by the physician for one of 32 sampled patients (Patient 17); and

3. To ensure the physician order for Levophed (medication to increase blood pressure) was administered as ordered, or an order indicating to hold the medication was obtained from the physician for Patient 23.

Together these failures had the potential to result in the delay and/or inaccurate treatment of the patient.
Findings:

1. A review of Patient 28's record was conducted. Patient 28 was admitted to the facility on on [DATE] , with abdominal pain and distention. A review of the "Physician's Order Sheet," noted a laboratory result dated May 29, 2012, at 6:1O a.m.which reflected a "critical value-Potassium
2.6 (a normal Potassium value is from 3.5 - 5.2)."
A review of the "Physician's order Sheet," dated May 29, 20 12, at 6:46 a.m., noted the physician ordered, "40 meq (milli equivalent) K rider (Potassium - to be introduced intravenously) now X 1(one time)," and "40 meq Potassium PO (orally) X 1," for Patient 28.
A review of the "Medication Administration Record," indicated Patient 28 received the, "40 meq K rider IVPB (intravenous piggy back X 1," and the "40 meq Potassium PO X 1," at 8:30 a.m.

An interview was conducted with the Registered Nurse (RN 10), on May 29, 2012, at 10:15 a.m. RN 10 stated he administered both the intravenous and the oral doses of Potassium to Patient 28. RN 10 stated the doses of Potassium were administered late.

A review of the facility policy, "Medication: Ordering, Transcription And Administration Of (Revised: 10/2011)," was conducted . The policy indicates,"NOW orders: Orders for medications written as now will be executed, including administration to the patient, within 1 hour from the time the order is written "
The doses of Potassium were administered 45 minutes past the allotted one hour time limit for "NOW" medication orders.

2. On May 29, 2012, the record for Patient 17 was reviewed. Patient 17 was admitted to the facility on on [DATE], with diagnoses including post motor vehicle accident and hyponatremia (low sodium in the circulating blood).

The "Medication Reconciliation Admission & Discharge Orders, Inpatient" dated May 28, 2012 at 11:00 AM, revealed the physician ordered the home medication,"Norco" (a pain medication) 5/325 mg (milligrams) one tablet to be given by mouth every six hours, and to "give as written" was checked.

The "Medication Administration Record" dated May 28, 20 12, at midnight to 11:59 p.m., revealed the order had been transcribed as "Norco 1 tab 5/325 mg PO (by mouth) PRN (as needed) pain
1-5 Q6hours (every six hours), " and the order had been checked by a nurse as correct Patient 17 was not given the "Norco" until 10:45 p.m.

The "Acute Care Nursing 24-Hour Flow Sheet" dated May 27, 2012, revealed Patient 17 was transferred to an inpatient bed from the emergency department on May 28, 2012, at 3:50
a.m., and at 6 a.m., Patient 17's was complaining of pain at a 4 on a pain scale of zero to 10 (10 being the worst pain).

The "Acute Care Nursing 24-Hour Flow Sheet" dated May 28, 2012, revealed:
a. At 7:30 a.m., Patient 17 was complaining of pain at a 5 on a pain scale of zero to 10.
b. At 11:55 a.m., Patient 17 was complaining of pain at a 10 on a pain scale of zero to 10, and was given Dilaudid (a pain medication) 1 mg intravenously (IV).
c. At 4:08 p.m., Patient 17 was complaining of increased pain at a 7, and was given Dilaudid 1 mg IV.
d. At 8:05 p.m., Patient 17 was complaining of pain at a 7 on a scale of zero to 10, and was given Dilaudid 1 mg IV.
e. At 10:45 p.m., Patient 17 was complaining of pain at a 7, and "Norco given per orders ."

During an interview with Nurse Manager (NM) 5, on May 29, 2012, at 11:10 a.m., she reviewed the record and stated if the order was correct, Patient 17 did not receive the "Norco" as ordered by the physician. NM 5 stated the nurse should have confirmed the order with the physician, and then accurately transcribed the order to the "Medication Administration Record."

The facility policy and procedure titled "Chart Check:24 Hour" reviewed April 2011, revealed "...The registered nurse (RN) will compare all orders on the physician's order sheet from the previous chart (check with the Medication Administration Record to insure that all orders have been transcribed correctly). Initial any validation checks required. In the event that there is a discrepancy between the order and the transcription, the error should be corrected at this time to prevent further delay in service or continuing error and the appropriate reporting system should be initiated.....

The facility policy and procedure titled "Physician's Orders" revised September 2011, revealed ...Pyhsician's Orders will be accurately processed and promptly followed..."

3. On May 29, 2012, Patient 23's record was reviewed. The patient presented in the
Emergency Department (ED) on May 28, 2012, at 4:36 p.m., with a chief complaint of status post
full arrest. The vital signs included a blood pressure of 76/51 mm/Hg (millimeter per murcury).

The physician's order dated May 28, 2012, at 6:29 p.m., included, "Levophed 2-8 mcg/min (microgram per minute) to keep SBP (systolic blood pressure; top part of blood pressure) >
100." The order was noted by the nurse at 7:03 p.m.

A review of the "Medication Administration Summary" indicated Patient 23 did not receive the Levophed. The record did not indicate documented evidence why the medication was not administered.

On May 29, 2012, at 3:10 p.m., in a concurrent interview with the Director of Emergency Services (DES), she was unable to find documented evidence that the Levophed was administered or documentation explaining why the medication was not administered.

On May 30, 2012, at 3 p.m., the DES was interviewed and stated she verified from the pharmacy department that Patient 23 did not receive the Levophed.She stated she spoke with the RN (RN 4; who cared for the Patient 23 in the ED) and stated the RN adjusted the dosing of another medication, which in effect increased Patient 23's blood pressure. The DES stated due to the increase in Patient 23's blood pressure, RN 4 informed the physician who subsequently ordered to hold the Levophed and to continue monitoring the patient's blood pressure. The DES stated the RN should have documented the care provided to Patient 23 and the conversation with the physician. In addition, the DES stated RN 4 should have written an order to hold the Levophed.

The facility policy titled, "Medication: Ordering, Transcription and Administration Of' dated October 2011, was reviewed. The policy indicated, "Medication Administration: All medications are to be administered by a licensed nurse...in accordance with the physician's
order..." The policy further indicated, "Withholding of Medications: Any medication may be held if in the licensed care provider's professional judgment giving the medication would be detrimental to the patient. The physician should also be notified and documentation should reflect notification and further medication orders to continue or discontinue the medication. The reason for withholding the medication must be documented in the medical record..."
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

All patient medical record entries must be legible, complete, dated, timed, and authenticated in written or electronic form by the person responsible for providing or evaluating the service provided, consistent with hospital policies and procedures.

This Standard is not met as evidenced by: Based on interview and record review,the facility failed to ensure the record for one of 32 sampled patients (Patient 13) was complete by including the name of the Respiratory Therapist (RT) attending Patient 13's delivery on the "Labor & Delivery Summary," the RT timing the "Progress Notes" dated May 29, 2012, and the placement of the RT's "Progress Notes" in Patient 13's record. This resulted in incomplete documentation on Patient 13's record.

Findings:

On May 30, 2012, the record for Patient 13 was reviewed. Patient 13, a newborn infant, was admitted to the facility on on [DATE], at 4:17 p.m., following a vaginal delivery. Patient 12 was Patient 13's mother.

The "Labor and Delivery Summary" dated May 29, 2012, revealed Patient 13 was born at 4:17 p.m., and a delivery physician, a scrub technician, a nursery registered nurse, and a registered nurse were in attendance for the delivery. The space for a respiratory therapist in attendance for the delivery was blank.

The record for Patient 12, Patient 13's mother, contained a "Progress Notes" dated May 29, 2012, revealed "pt (Patient) baby girl born vaginally (with) vacuum - first cry at birth canal immediately (after) birth. Dried, warmed & stimulated. ..." The "Progress Notes" was signed by a Registered Respiratory Therapist. The "Progress Notes" was not timed, and was not included in Patient 13's record.

During an interview with RN 20, on May 30, 2012, at 11:50 a.m., she stated it was the Labor & Delivery (L&D) nurses responsibility to record who was in the room during a delivery. RN 20 stated the Respiratory Therapist was in the room for the delivery of Patient 13, but she did not write their name on the "Labor & Delivery Summary" because she did not know the persons name. In addition, RN 20 stated she could not tell when the Respiratory Therapist's progress note was written because the note was not timed, and the "Progress Notes" was placed in the mother's record not Patient 13's record.

The facility policy and procedure titled "Documentation Content: Medical Record" reviewed December 2010, revealed "... Each entry that is made in the record shall be legibly signed by the person making the entry, encouraged to print name, dated, and timed. The date and time shall be the date and time that the entry is made. ... Each inpatient medical record shall consist of at least the followingitems: ...Other ancillary department treatments,reports, therapy and documentation. ..."
VIOLATION: PHARMACY DRUG RECORDS Tag No: A0494
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Current and accurate records must be kept of the receipt and distribution of all scheduled drugs.

This Standard is not met as evidenced by: Based on interview and record review, the facility failed to ensure its Medication Reconciliation Process (definition below) was implemented correctly for one of 32 patients, (Patient 31). This failure could lead to errors with medication management potentially impacting the provision of medical care.

Findings:

A review of Patient 31's record was conducted. Patient 31 was admitted to the facility on on [DATE].The history and physical, dated May 29, 2011, indicated the patient has [DIAGNOSES REDACTED] (brain dysfunction), secondary to a low blood sugar and a urinary tract infection.

A review of the list of medications the patient had been receiving at the board and care residence where she resided was conducted.The medication list reflected ten medications Patient 31 was receiving prior to her admission to the facility.

A review of the "Medication Reconciliation, Inpatient," document dated May 29, 2012, at 5:15
p.m., was conducted on May 30, 2012. The document reflected a list of nine medications Patient 31 was taking prior to her admission to the facility.

One medication present on the medication list brought in with the patient, Nitrofur Mac (an antibiotic generally used to treat urinary tract infections,) was not documented by the nursing staff onto the "Medication Reconciliation, Inpatient" document.

An interview was conducted with the Registered Nurse, (RN 11) on May 30, 2012, at 11:15 a.m. RN 11stated the Medication Reconciliation document (MRD) is completed by the nurses on the unit the patient is admitted to. RN 11 stated nurse completing the MRD for Patient 31 did not transcribe the Nitrofur Mac from the patient's current list of home medications onto the MRD. RN 11 further stated she will call the physician to determine if the patient needs to continue with the medication.

A review of the facility policy,"Medication Reconciliation Across the Continuum of Care (Revised October/2011)," was reviewed. The policy defines Medication Reconciliation as,"The process of identify ing the name, dosage,route and frequency for every medication currently being taken and ordering medication based on reference to this list....it is the policy to reconcile patient's medications at the time of admission..."

The purpose of the policy , "...is to accurately and completely reconcile medications across the continuum of care to prevent discrepancies, reduce adverse drug events and promote a safe patient care environment."
VIOLATION: DELIVERY OF DRUGS Tag No: A0500
In order to provide patient safety, drugs and biologicals must be controlled and distributed in accordance with applicable standards of practice, consistent with Federal and State law.

This Standard is not met as evidenced by: Based on observation, interview, and facility document review, the facility failed to ensure the neonatal crash cart (a cart that contained supplies, including medications for cardiac and/or respiratory arrest), located in Campus 1's Emergency Department (ED), was controlled according to facility policy. This failure had the potential for the cart to have inadequate emergency supplies, which may delay emergent care and treatment of neonates.
Findings:
On May 29, 2012, at 10:20 a.m., Campus 1's ED was toured. The department had one neonatal cart located in one of the trauma rooms. The May 2012 "Neonatal Crash Cart Checklist" was reviewed. The document indicated: - The cart was not checked on May 4, 6, 7, 8, 9, 10 , 11, 12, 13, 15, 17, 18, and 27, 2012; and - On May 14, 2012, Not locked - called Pharmacy? (Question) if cart complete." The document indicated the following lock numbers:- May 16, 2012 - 54; - May 19 through May 25, 2012 - 57 ; and - May 26, 2012 - 00. On May 29, 2012, at 10:25 a.m., RN 2 was interviewed RN 2 stated the neonatal crash cart was checked daily.

On May 30, 2012, at 8:35 a.m., RN 3 was interviewed and stated she was the nurse who checked the neonatal crash cart on May 14, 2012. RN 3 stated she could not recall whether the cart's lock was missing or broken. She stated she asked the pharmacy department to check if the cart had any missing supply.

On May 30, 2012, at 9:20 a.m., the Pharmacy Department's Neonatal Crash Cart log was reviewed with the Pharmacy Manager (PM) for Campus 1. She stated Campus1 only had one neonatal crash cart and was located in the ED. The log indicated the following lock numbers: - May 15, 2012 - 54; - May 16, 2012 - changed to 57 - May 17, 2012 - changed to 71; and
- May 25, 2012 - changed to 00.

In a concurrent interview with the PM, she stated there was a discrepancy in the documentation of the neonatal crash cart lock checks performed by the ED staff and the actual lock issued by the pharmacy department.

The facility policy titled ,"Code Cart Integr ity and Restocking Process" dated September 2011,was reviewed. The policy indicated , "Code Cart Routine Check for Integrity: The department manager or designee(s) will assign an employee to check the emergency cart daily...Check the cart for intact lock...Document on the Cart Check list the following...Record lock number on Code Cart Checklist..."
VIOLATION: EMERGENCY POWER AND LIGHTING Tag No: A0702
There must be emergency power and lighting in at least the operating, recovery, intensive care,
and emergency room s, and stairwells. In all other areas not serviced by the emergency supply source, battery lamps and flashlights must be available.

This Standard is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure emergency
lighting was available to all operating rooms (OR). This had the potential to result in no lighting being available during a surgical case in the event of electrical power failure and a subsequent failure
or delay of the emergency generators to provide back-up power.

Findings:
On May 30, 2012, at 9 a.m., a tour of the OR Campus 2 was conducted with the Director of Surgery. There was no visible battery operated lighting in any of the OR's. She stated that emergency power was provided by a generator, in the same way as it was at Campus 1. She did not know if there was any battery operated lighting to ensure uninterrupted lighting during the transition time it took for the generator to power up, or if the generator switch failed.

On May 30, 2012, at 930 a.m., during a tour of the Cardiac Cath Lab, the Lead Radiology Tech and the Registered Nurse (RN 1) stated the emergency power was from a generator. They did not know if there was any battery operated lighting, that would immediately turn on and prevent any delay in lighting, untilthe generator was able to take over.

On May 30, 2012, at 2:10 p.m., the Director of Plant Ops (DPO) was interviewed . The DPO stated, two of five OR's at Campus 1, and both of the Labor and Delivery OR's at Campus 2, had lighting that was equipped with built in capacitors that would immediately switch over in the event of a power failure, and could provide up to 90 minutes of lighting. The DPO stated three OR's, an Endoscopy Room, and a Special Procedure Room at Campus 1; three OR's and the Cardiac Cath Lab at Campus 2, were not equipped with a source that could provide for uninterrupted lighting in the event of a power outage.
VIOLATION: TRANSFER OR REFERRAL Tag No: A0837
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**


The hospital must transfer or refer patients, along with necessary medical information, to appropriate facilities, agencies, or outpatient services, as needed, for follow-up or ancillary care.
This Standard is not met as evidenced by:
Based on interview and record review, the facility failed to ensure a medically safe discharge and/or transfer was implemented for one of 32 patients, (Patient 18). This failed practice could result in serious or potentially fatal consequences if
Patient 18's medical and medication needs were not met in a timely manner post discharge as the patient was actively being treated with an injectable blood thinner, Lovenox, for a blood clot in her right arm.
Findings:
A review of Patient 18's record was conducted. Patient 18 was admitted to the facility on on [DATE], with a diagnosis of [DIAGNOSES REDACTED].
On February 22, 2012, the patient was diagnosed with [DIAGNOSES REDACTED]
A review of the discharge planning notes documented by the care coordinators (CC) and their assistant indicated from February 20 through February 23, 2012, four higher care level facilities were contacted multiple times regarding their availability to accept Patient 18. All four facilities indicated they were full, with no beds available.
A review of the Physician's Order Sheet, dated February 23, 2012, at 12:30, indicated, "DIC (discharge) (pt's (patients) family will take pt transport to (the name of an emergency room )."
A review of the physician's discharge dictation, dated February 23, 2012, at 12:34 p.m., was conducted. The document indicated,
"After discussion with the family, the patient obviously wanted to go to the Tertiary Care (higher level of care); however currently, the bed is not available and transfer could take a long time. As such, the patient's family wanted to discharge the patient and directly bring the patient to the emergency room either at (two other acute care hospitals) today. After discussion with (the pulmonologist), it is okay to discharge the patient and by counseling about thoracentesis (test is which fluid is removed from the lungs) today, and we will give just 1 dose of Lovenox 1 mg/kg (milligram per kilogram) for right thrombosis (blood clot) and the patient should continue the pain medications and hopefully, the patient can reach the emergency room within 12 hours of time frame and then can be managed at Tertiary Care for this metastatic cancer."
An interview was conducted with CC 1on May 31, 2012, at 9 a.m. CC 1stated when a patient is transferred to a higher level of care one needs to have a physician's order as well as an accepting physician at the facility. If there are no beds available then the search for an appropriate facility would be expanded.
CC 1 stated if the patient is insistent upon being transferred to a higher level of care without an available bed, the physician needs to explain to the patient and the family that the transfer is not safe. If they are still insistent the patient would have to leave against medical advice.
CC 1 further stated, regarding Patient 18, that it did not appear the patient was stable as the patient had a blood clot in her arm and to discharge the patient would not be safe as further treatment was required. The CC stated the risks of transfer could potentially result in the dislodging of the blood clot, also the patient may not make it to the higher level facility to receive her next dose of her blood thinner, (Lovenox).

An interview was conducted on May 31, 2012, at 9:50 a.m., with the Registered Nurse, (RN 9), who discharged Patient 18. RN 9 stated you cannot discharge a patient to an emergency room (ER). RN 9 further stated you must have a physician at the other facility to accept the patient.

RN 9 stated the patient's family was insistent the patient go to a higher level of care to have her cancer treated. RN 9 stated she should have reviewed the case with the charge nurse who would take it up the chain of command as needed.

A review of the facility policy, "Transfer: To Higher or Lateral Level of Care, Rehabilitation or Skilled Nursing Facility (Revised 6/2011)" was conducted. The guidelines for transferring a patient to a higher or alternative level of care indicate; -"The sending physician obtains an accepting physician. The physicians must have a physician to physician report.
-The receiving facility will be notified of the transfer. The Care Coordinator/designee will place a call to intake bed coordinator at the accepting facility.
-The transfer will not occur until the receiving physician and receiving facility have accepted the patient, and there is bed availability at the appropriate level of care."
A review of the facility policy, "Discharge Planning (Revised: 6/2011)" indicated,"Care Coordinator/Social Worker confirms transfer arrangements if the patient is being transferred to another facility, including confirming facility acceptance ..."

An interview was conducted with the Nurse Manager (NM 1) on May 31, 2012, at 10 a.m., who stated during a discussion of Patient 18's discharge/transfer situation, "This is not our practice, we do not do this0
VIOLATION: EMERGENCY SERVICES Tag No: A1100
The hospital must meet the emergency needs of patients in accordance with acceptable standards of practice.

This Condition is not met as evidenced by: Based on observation, interview, and record review, the facility failed to meet the emergency needs of patients with obstetrical-related complaints at Campus 1 ED (Emergency Department), in accordance with the facility's established process by failing to:

1. Ensure fetal assessmenUre-assessment , to include fetal heart tones (FHTs) was completed for all OB patients 20 weeks or above (Refer to A1103);

2. Ensure the Labor and Delivery (L&D) nurse was called immediately according to the facility's established process (algorithm) for OB patients 20 weeks or above EGA (Estimated Gestational
Age; fetus' age in weeks) (Refer to A 1103; A395);

3. Ensure OB patients 20 weeks or above EGA, including the fetus' status, were assessed and monitored, and not sent back in the waiting room, without direct supervision (Refer to A1103 ; A395) ; and

4. Establish an accurate Estimated Gestational Age, which determined how the patient and fetus were going to be treated and cared for (Refer to A 1103; A395 ).

The cumulative effect of these systemic problems resulted in the failure of the facility to provide emergency needs of pregnant patients' emergency medicalcondition, including the fetus' condition.
VIOLATION: INTEGRATION OF EMERGENCY SERVICES Tag No: A1103
[If emergency services are provided at the hospital -1

(2) The services must be integrated with other departments of the hospital.

This Standard is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure emergency services provided in Campus 1's ED were
consistently integrated with obstetrical services, in accordance with the facility's established process (algorithm) designed for obstetrical patients, identified as 20 weeks of pregnancy or above, with obstetrical-related complaints. Emergency services failed:

1. To ensure the ED RN conducted an accurate nursing assessment and evaluation of Patient 10, when fetal heart tones (FHTs) were not obtained and the Labor and Delivery (L& D) nurse was not called immediately according to the facility's established process (algorithm), and based on the facility's determination of Patient 10 being seven months pregnant. Nursing service also failed to monitor Patient 10 when she was sent back to the waiting room without direct supervision.

This resulted in a delay in care and the possible delivery of a premature infant (infant born before the 37th week of pregnancy).

2. To ensure the ED RN conducted an accurate nursing assessment and evaluation of Patient 24, when fetal heart tones were not obtained and the Labor and Delivery (L&D) nurse was called immediately according to the facility's established process (algorithm), based on the facility's initial determination of the patient's Estimated Gestational Age of 27 weeks (EGA; fetal age in weeks). Nursing service also failed to ensure the patient, including the fetal status (initially determined to have an EGA of 27 weeks) was assessed and monitored, and not sent back to the waiting room without direct supervision. Nursing service failed to establish an accurate EGA, which determined how the patient and fetus were going to be treated and cared for.

These failures had the potential in delay in assessment, treatment, and the care of the pregnant patients' emergency medical condition, including the fetus' condition, which could subsequently result in harm, serious disability or injury, up to death of the patient and/or the fetus.

Findings:

Background: The facility has two campuses , both with an Emergency Department (ED). In December 16, 2011, Campus 1's Labor and Delivery Department, which provided services for Obstetrical (OB) emergencies was closed and integrated with Campus 2's Women's Services. Since then, any pregnant patient presenting themselves in Campus 1's ED had to be evaluated within the capabilities of the ED.

The facility had established a process (algorithm) to follow when a pregnant patient arrived at Campus 1's ED.The "algorithm" indicated:

Step 1: Pregnant patient (20 weeks and above) presents to the ED either by private auto, or ambulance;

Step 2: Patient is seen by provider who performs MSE (Medical Screening Exam) and ED RN
obtains Fetal Heart Tones (FHT);

Step 3: Check for FHT 120 to 160

a. If yes, does the patient have an OB related complaint?
- If yes, proceed to Step 4
- If no, the patient will be treated like a normal ED patient

b. If no, Is the patient in apparent or suspected labor or need fetal monitoring?
- The next step is Step 4
Step 4:
a. ED Charge Nurse will: - Immediately call OB charge nurse at Campus 2 who assigns an L&D RN to respond to Campus 1 ED; and Assign primary ED RN
b. ED Unit Secretary will: -Immediately call (ambulance company) to notify them of either transport STAT or possibility of transport

Step 5: L&D RN:
- Completes OB evaluation;
- Consults with ED Physician; and
- Notifies OB Physician

Step 6: ED Physician, L&D RN,and OB Physician will determine if the patient is stable for transfer/or discharge. If trauma patient, Trauma Physician will be involved in the disposition of patient.

Step 7: Is patient stable for discharge?
a. If yes, discharge the patient with appropr iate follow-up
b. If no, proceed to Step 8

Step 8: Is patient stable for Transfer?
a. If yes. Unit Secretary notifies (ambulance company); ED RN fills out transfer paperwork; L&D RN may go with the patient. The patient is transferred.

b. If no, the patient is move to appropriate room for impending delivery. The ED team gathers necessary equipment and calls RCP (Respiratory Care Practitioner) to standby .

Step 9: After the patient has delivered and is stabilized, prepare for transfer.

1. On May 30, 2012, the record for Patient 10 was reviewed. Patient 10 presented on May 29, 2012, at 9:07 p.m. The "ER (emergency room ) Demographics" revealed Patient 10 was complaining of "back/abdominal cramping after being hit in the stomach - 7 months pregnant."

The "Emergency Record" dated May 29, 2012, revealed:
a. At 9:07 p.m., Patient 10 was "GREETED" by RN 21 and was placed in the waiting room on "BED WAIT."
b. At 9:40 p.m., RN 21 "triaged" Patient 10 and determined she was "29 and 5 days pregnant, with lower abdominal pain with cramping."
c. At 10:54 p.m., the Physician's Assistant (PA) 3 initiated the medical screening examination for Patient 10 and "Per customary practice initial diagnostic studies ordered at this time to expedite patients care. Capacity issues have prevented immediate bedding. Patient is stable for the waiting room, informed of plan and advised to alert the greeter RN for any change of condition."

No FHTs were obtained, and laboratory tests specific to Patient 1O's chief complaint of abdominal trauma and cramping/preterm labor were not ordered.

There was no documentation in the record as to when the OB nurse was called to respond to the Campus 1 ED to evaluate Patient 10.

The Campus 1 "Emergency Department Algorithm for OB Patients" dated April 19, 2012, revealed "Pt (patient) is seen by provider who performs MSE (medical screening examination) ED RN obtains Fetal Heart Tones" and if the patient had an OB related complaint, the ED Charge Nurse would "immediately" call the OB Charge Nurse at Campus 2 who assigned a L&D RN from Campus 2 to respond to the Campus 1's ED.
The "OB Outpatient Record" dated May 30, 2012, was initiated by the OB nurse at 12:07 a.m.
Patient 10 was placed on an external fetal monitor, and at 12:15 a.m., the baseline FHTs were 130, with moderate variability (the ability of the fetal heart to respond to external stimuli through a well balanced nervous system) and there was positive fetal movement. The obstetrical physician was called at 12:30 a.m.

The "Outpatient Observation Orders" dated May 30, 2012, at 12:45 a.m., revealed laboratory tests were ordered to include a fetal fibronectin (helps predict preterm delivery), and a Kleihauer-Betke (detects and measures the number of fetal cells in the mother's blood. This test is used to predict certain types of pregnancy complications, particularly after a mother has suffered a traumatic injury.) In addition, medication was ordered to stop Patient 1O's contractions.

On May 30, 2012, at 3:45 a.m., Patient 10 was transported via ambulance to the Labor & Delivery unit at Campus 2.

On May 31, 2012, at 9:30 a.m., a tour of the Campus 1 ED was conducted.

During an interview with the Campus 1 ED Charge Nurse (RN 13) , on May 31, 2012, at 9:45 a.m., she stated all patients greater than 20 weeks gestation "get FHTs," and if the patient presented with a pregnancy related complaint, she would initiate the L&D nurse coming over from Campus 2 to the Campus 1 ED. RN 13 stated they were "supposed to put in the record when the OB nurse was called and when the OB nurse arrived" at the Campus 1 ED. In addition, RN 13 stated she would not place the patient back in the waiting room.
During an interview with the Director Emergency Services (DES) on May 31, 2012, at 11:40 a.m , she reviewed the record and was unable to find documentation of FHTs until three hours after Patient 10 arrived at the Campus 1 ED, and when the Campus 2 OB nurse was called to respond to the Campus 1 ED. In addition, the DES stated Patient 10 should have had a fetal assessment to include FHTs and should not have been placed in the waiting room.

During a telephone interview with RN 21, on May 31, 2012, at 2:05 p.m., she stated she "GREETED (first encounter with an RN for an ED patient)" Patient 10, assigned her an Emergency Severity Index Level 3 [patients requiring two or more resources,done on a Level 1 (most ill patients) through Level 5 scale], and had Patient 1O return to the waiting room. RN 21 stated she gave the "paper work" to the Treatment & Procedure Nurse and she called the ED Charge Nurse to tell her there was a pregnant patient greater than 20 weeks gestation in the ED waiting room. In addition, RN 21 stated the ED was busy so she later "triaged" Patient 10 for the Treatment & Procedure Nurse at the "GREET" desk, and she could not obtain the FHTs because she could not provide privacy for Patient 10 at the "GREET" desk. RN 21 stated when she was the Treatment & Procedure Nurse, she always obtained the FHTs.

2. The facility's document titled,"[Campus 1's name] Emergency Department Algorithm for OB Patients" revised April 19, 2012, was reviewed. The document indicated:

- When pregnant patients (20 weeks and above EGA) presented to the ED, the patient needed to be seen by the provider who performed a MSE and the ED RN obtained Fetal Heart Tones
(FHTs); and

- When a patient was in "apparent or suspected labor or need fetal monitoring," the ED Charge Nurse called the OB charge nurse at Campus 2 immediately and assigned a L&D RN to respond to Campus 1's ED...Assigns primary ED RN...ED Unit Secretary immediately calls (Ambulance Company's name) to notify them of either transport STAT or possibility of transport.

On May 30, 2012, Patient 24's record was reviewed. The patient presented to Campus 1's ED on May 9, 2012, at 12:28 a.m.,with chief complaints of stomach cramps and 5 months pregnant.

The "Imaging Patient Pregnancy Questionnaire (Age 12 to 55 years) ," was filled out upon arrival in the ED. The document indicated Patient 24 was pregnant, with the first date of her last menstrual period (LMP - used to determine the EGA) being January 13, 2012.

The "Emergency Record" indicated the patient triaged (process to determine the priority of complaint) on May 9, 2012, at 12:42 a.m. The record indicated the patient's complaint as, "5 Months pregnant cramping...on and off lower abd(omen) cramping since 4 hrs (hours) ago..." The record did not contain documented evidence fetal heart tones were obtained or an attempt was made to obtain them.

The "HPI (History of Present Illness) Abdominal Pain" conducted by the practitioner (Physician Assistant [PA] 3) on May 9, 2012, at 1:01 a.m., indicated, "Patient presents for evaluation of abdominal pain...onset 1 hour ago...associated with loss of appetite and nausea...Patient with lower abdominal pain 27 weeks with cramping s/p (status post) fall today. No vaginal bleeding or discharge." There was no documented evidence the fetal condition was assessed.

On May 31, 2012, at 3:20 p.m., RN 5 (the triage nurse for Patient 24) was interviewed by phone. RN 5 was unable to recall the situation with Patient 24. RN 5 stated the facility's practice was when a pregnant patient came to the ED, the patient was immediately brought in the RME area for evaluation. Once the pregnant patient was identified to be 20 weeks or above,the L&D
nurse (from Campus 2) was called to come in to care for the patient.

The "Orders" dated May 9, 2012, at 12:57 a.m., included, "Call L&D Nurse for clearance." The record did not contain documented evidence the L&D nurse was called.

On May 31, 2012 , at 10:50 a.m., RN 6 (l&D RN in Campus 2's Women's Services) was interviewed. RN 6 stated Campus 1's ED would call their department when a RN needed to go to Campus 1's ED for a pregnant patient 20 weeks and above, with OB related complaints. When it was determined a L&D nurse needed to be sent to Campus 1 ED, the expectation was the nurse should arrive within 30 minutes. The L&D nurse would sign out in the log to indicate the time of departure from the Women's Services unit (located in Campus 2). She stated if a patient was less than 20 weeks pregnant, the nurse would not be sent according to the facility policy.During the interview with RN 6, the DWS (Director of Women's Services) and L&D Manager (LDM) were present and agreed that the L&D nurse should be at Campus 1's ED within 30 minutes when required to be there.

On May 31, 2012, at 9:30 a.m., RN 13 (Campus 1's ED RN) was interviewed. She stated if a pregnant patient (20 weeks or above) presented in the ED, the patient was immediately placed in the RME area, the L&D nurse was called immediately, and was expected to get to the ED within 30 minutes.

The facility document titled,"Daily Float Hours to [Campus 1's name] ED" was reviewed. The log indicated RN 12 signed out at 1:45 a.m. (approximately 1 hour and 17 minutes after Patient 24 presented herself in the ED and 48 minutes after PA 3 ordered the L&D nurse to be called).

The "Emergency Record" indicated the L&D RN (RN 12) was at Patient 24's bedside on May 9, 2012, at 2:10 a.m. (approximately 1 hour and 43 minutes after Patient 24 presented herself in the ED and 1 hour and 13 minutes after PA 3 ordered the L&D nurse to be called).

On May 31, 2012, at, 2:35 p.m., a phone interview was conducted with RN 12 (L&D nurse that was sent to Campus 1's ED for Patient 24). RN 12 stated Campus 2's Women's Services received a call from Campus 1's ED requesting to have a L&D care for Patient 24's OB concerns. RN 12 stated she received preliminary information that Patient 24's EGA was 23 or 27 weeks and the patient was having abdominal pain.

The "Doctor Notes" documented by PA 3 on May 9, 2012, at 1:01 a.m., indicated, "...MSE (Medical
Screening Exam) initiated in RME [Rapid Medical Exam - also known as TAP (Treatment and Procedure) area)...Capacity issues have prevented immediate bedding. Patient is stable for waiting room, informed of plan and advised to alert the greeter RN for any change of condition..." There was no documented evidence the fetalcondition was assessed.

The "Orders" dated May 9, 2012, at 12:57 a.m., included, "Call L&D Nurse for clearance."

A request was made for a policy and procedure which indicated the Campus 1 ED's process for pregnant patients who presented themselves to the ED. The facility did not have specific policies addressing Campus 1's process considering the campus no longer had the Labor and Delivery unit available.

The facility policy titled, "Triage: Five Level (Emergency Department Specific)" dated April 2011, indicated, "Pregnant Patients Only:

Pregnant women (greater than 20 weeks gestation) may be triaged out of the Emergency Department to the Women's Center;

Pregnant women stable for immediate transport to the Labor & Delivery unit do not need to be registered or triaged in the emergency department;

Pregnant women will be transported directly to Labor & Delivery by hospitalpersonnel on a stretcher or wheelchair; and

If there is no pregnancy-related complaint, if the patient is unstable, or if the triage RN is unsure of appropr iateness of transport to Labor & Delivery, a quick triage will be completed and the provider will clear the patient for transport or full triage and registration in the ED."

On May 31, 2012, at 9:20 a.m., RN 14 (assigned as the "greeter/first patient contact" in the ED) was interviewed and stated if a patient presented to the ED and was identified as pregnant, information required to have was the date of their LMP. The computer automatically computed the patient's EGA RN 14 stated it was significant to determine the patient's EGA to determine the nature and level of urgency to treat the patient with their chief complaint related to why the patient was being seen in the ED. If a patient was more than 20 weeks with the EGA, the Campus 2
- Women's Services' charge nurse was immediately called to send a L&D nurse to Campus 1 ED.

On May 31, 2012 , at 9:30 a.m., RN 13 (Campus 1's ED RN) was interviewed. She stated if a pregnant patient (20 weeks or above) presented to the ED, the patient was immediately placed in the RME area, the L&D nurse was called immediately and was expected to get to the ED within 30 minutes. RN 13 stated the patient's EGA was determined by inputting in the computer system the patient's LMP, and it will automatically indicate the patient's EGA RN 13 stated the EGA was determined to identify the type of treatment and response the patient needed.

The facility policy titled,"Bed Placement: Obstetrical Patient (Women's Services Specific)" dated April 2011, was reviewed and indicated,

"The labor and delivery Charge Nurse or designee determines appropriate placement of the patient; As obstetrical beds become limited the Charge Nurse/designee will triage by acuity;

Patients unable to be placed in a patient room at the time they present to the unit will be evaluated by the charge nurse or designee, completing the OB intake form to determine acuity according to the patient's responses...Fetal Movement...Contracti ons (frequency, strength and duration)...; and

Patients not assigned to an obstetrical bed will be reassessed every thirty minutes or promptly upon patient report of status change. Information will be documented in the patient's medical record..."

On May 31, 2012, at 11:05 a.m.,Patient 24's record was reviewed with the DES, DWS, and LDM.The DES stated the record indicated the patient was considered as having an EGA of 27 weeks. The DES was unable to find documented evidence the ED staff attempted to obtain the patient's FHTs or whether they were unobtainable. The DES and DWS stated Patient 24's FHT should have been obtained or if unobtainable should have documented as such. Both were not able to find a complete obstetrical assessment that included an accurate determination of the patient's EGA (actually 16 517 weeks) and the fetal condition.

On May 31, 2012, at 1:45 p.m., Patient 24's record was further reviewed with the DES, DWS, and LDM. The DES stated,with the patient being identified as having an EGA of more than 20 weeks, there was a delay in getting the L&D nurse to Campus 1's ED.

In the same interview, the DES stated in a "hindsight" review of Patient 24's record,she stated the patient should not have been placed back in the waiting room. During further interview, the DES and DWS stated since the closure of the L&D unit in ED Campus 1, verbal communication had occurred between them. The DES stated there was no documented evidence that the care being provided to patients (in Campus 1 ED), 20 weeks and above (with OB related complaints), were being monitored since the closure. The DWS stated data related to the provision of care for pregnant patients were monitored in Campus 2's Women's Services, but did not include the pregnant patients in Campus 1's ED. Both directors stated there had not been any review of patient records specific to pregnant patients seen in Campus 1's ED as there had not been any concerns brought to their attention since the closure on December 16, 201 1.

On May 31, 2012, at 5:20 p.m.. the CEO, CNO, COO, CMO, and ORM were notified Immediate Jeopardy (IJ) was identif ied. The IJ was identified due to the facility's failure to conduct assessment and treatment of pregnant patients, 20 weeks or above, with OB-related complaints consistent with the facility's established process (algorithm) in Campus 1's ED. Furthermore, the facility failed to integrate the care and treatment of these patients with the obstetric department, in accordance with the facility's established process. These failures created potential delay in assessment, treatment, and the care of the pregnant patients' emergency medical condition, including the fetus' condition, which could subsequently result in harm, serious disability or injury, up to death of the patient and/or the fetus.
The facility submitted an acceptable written plan of correction for the IJ identified on May 31, 2012, at 8:01 p.m.
The facility had requested and submitted a revised plan of correction on June 1,2012, at 12:07 p.m. The revised written plan of correction was reviewed and accepted on June 1, 2012, at 12:30 p.m.
The survey team validated the facility's plan of action to resolve the immediate jeopardy situation, on June 1, 2012, at 1:40 p.m., and ongoing observations, interviews, and record reviews revealed the facility implemented the following action plan: The facility provided education to the ED practitioners that any patient identified 20 weeks or above that came in with an OB-related complaint will be evaluated by a physician before the patient may be triaged to the waiting room. The facility will be documenting the assessment/MSE in the patient's record including pertinent negative findings. The documentation will include, at a minimum: an estimate of fetal age, such as EGA, LMP or EDC, fetal heart tones, fetal movement as reported by the mother, pain assessment, presence of vaginal bleeding or discharge. In addition, the facility revised the "algorithm" and had provided education to the staff on the revisions.

After implementation of the acceptable plan of correction, the CEO was notified the IJ was removed on June 1, 2012, at 4:05 p.m.
VIOLATION: ADEQUATE RESPIRATORY CARE STAFFING Tag No: A1154
There must be adequate numbers of respiratory therapists, respiratory therapy technicians, and
other personnel who meet the qualifications specified by the medical staff , consistent with State law.

This Standard is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure qualified personnel for neonatal resuscitation (Respiratory Care Practitioner/RCP) was knowledgeable of the availability of neonatal emergency equipment and the difference between other age-group emergency equipment. This failure had the potential to result in delay and mistreatment of a neonatal cardiac and/or respiratory arrest in the ED.

Findings:

On May 29, 2012, at 10:20 a.m., during a tour of Campus 1's ED, the neonatal crash cart was observed in Trauma Room 8 and 9. The May 2012 "Neonatal Crash Cart Checklist" indicated the cart was not checked daily (Refer to A500).

On May 29, 2012, at 10:25 a.m., the Director of Emergency Services (DES) was interviewed and stated the ED RNs were not Neonatal Resuscitation Program (NRP) certified. She stated all the RCPs were NRP certified and would respond to any cardiac and/or respiratory arrest (Code white) of neonates, from a pregnant mother that delivered a newborn or a neonate (28 days or less) that visit the ED. The DES stated the neonatal crash cart (supplies and medications used for babies up to 28 days old) used to be in a different location (not in the trauma room), in one of the ED's cove.

On May 30, 2012, at 8:55 a.m., RCP 1was interviewed. RCP 1 stated she was assigned in the ED and would respond to a neonatal "code white." She stated she was NRP certified. RCP 1 stated if a neonate in the ED went in cardiac and/or respiratory arrest, she would respond and bring the pediatric crash cart (containing different supplies and medications compared to a neonatal crash cart) for the code. RCP 1was unaware a neonatal crash cart was available in the ED. RCP 1 stated there was no difference between a neonatal and a pediatric crash cart.