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.

PORTNEUF MEDICAL CENTER 777 HOSPITAL WAY POCATELLO, ID 83201 Jan. 26, 2017
VIOLATION: EMERGENCY SERVICES Tag No: A1100
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interview, review of policies, observation, and medical records, it was determined the hospital failed to ensure care was provided to meet the needs of 12 of 32 patients (#1, #5, #6, #7, #9, #15, #16, #17, #20, #21, #23, and #32) whose ED records were reviewed. This resulted in unmet patient needs. Findings include:

1. Patient #16 was a [AGE] year old male who (MDS) dated [DATE] at 5:56 PM. He was emaciated. A triage note by the RN, dated 1/04/17 at 6:06 PM, stated Patient #16 was 6 feet 1 inch tall and weighed 80 pounds. Patient #16 had a urinary catheter. His ability to ambulate, transfer, and care for himself was not documented.

A physician examination was documented on 1/04/17 at 11:40 PM. It stated Patient #16 was sent from a SNF, where he resided, to the ED and said "...he has been refusing to eat or drink and refuses [to] take antibiotic for UTI. He has also been depressed and trying to hang himself [with] the bed sheet." The physician documented on 1/04/17 at 11:43 PM, that Patient #16 had malaise, weakness, anxiety, depression, emotional lability, hallucinations, and suicidal ideation. The note further stated Patient #16's affect was abnormal and flat and his judgment and insight were poor.

An assessment by an LSW for the Behavioral Health Assessment Team was dated 1/04/17 beginning at 8:28 PM. It stated Patient #16 was accompanied in the ED by the administrator of the SNF where he resided. It stated Patient #16 had "...a history of suicide attempts, usually by wrapping his bed sheet around his head & throwing himself onto the floor." The note stated Patient #16's behaviors were beyond the SNF's ability to care for him. The note stated "Rationale for Admission to Inpatient Psychiatric Treatment: Ongoing suicidal ideations. Therefore, ER social worker requests that patient be reviewed for admission to [Behavioral Health Unit]." The note stated the hospital associated with the SNF where Patient #16 resided refused to accept him for treatment.

Subsequent notes by the LSW on 1/04/17, stated the psychiatric units at Portneuf Medical Center and 2 other hospitals refused to accept Patient #16 for treatment. An LSW note at 9:41 PM, stated Portneuf Medical Center refused to admit Patient #16 because he required "Gero-Psych level of care."

Patient #16 was kept in the ED overnight.

The LSW documented, on 1/05/17 at 8:27 AM, that he contacted the state Adult Mental Health worker for assistance with placement.

The SNF where Patient #16 resided had a psychiatric hospital associated with it. Both facilities had the same base name.

The LSW documented, on 1/05/17 at 2:17 PM, he contacted both facilities. He documented he was told Patient #16 was not appropriate for treatment at that hospital nor the associated SNF. Then, the same note stated "...patient [#16] has been discharged back to [base name of facilities] via ambulance, via ED MD orders." The note did not state whether Patient #16 was discharged to the hospital or the SNF. Then the same note stated the LSW was told the administrator of the receiving facility met the ambulance in the parking lot and refused to admit Patient #16.

The final note by the LSW, dated 1/05/17 at 6:20 PM, stated the Adult Mental Health worker got Patient #16 admitted to a critical access hospital in the area. The note stated "Patient returns to ED simply for transfer to non-emergent ambulance."

The ED physician documented, on 1/05/17 at 12:03 PM, that Patient #16's diagnosis was "acute on chronic psychosis." The note stated "Disposition Type: Discharge, Disposition: Home, Disposition Transport: Private Vehicle, Condition: Stable." This was not accurate. Patient #16 was transported by ambulance. The use of the term "Home" was also inaccurate.

Another ED physician note, dated 1/05/17 at 12:56 PM, stated Patient #16 was medically cleared and had no acute medical issues. The note stated "Plan is to send him back to his care facility, where multiple personnel are working on long term plans for an inpatient psychiatric facility, as an outpatient. No acute events in the emergency department. Patient discharged in stable condition."

The physician documentation did not state that Patient #16 was psychiatrically stable. The physician documentation did not mention that the facility Patient #16 was being sent to had clearly refused to accept him for treatment. The physician documentation did not mention communication with the LSW.

Physician A was the physician who cared for Patient #16 after 7:00 AM on 1/05/17. He was interviewed on 1/26/17 beginning at 9:10 AM. He stated Patient #16 was medically cleared. He stated Patient #16 needed treatment at a geriatric psychiatric facility. He stated he spoke with the LSW who was not sure about placement plans for Patient #16. He stated he called the SNF administrator. He stated the SNF could not take Patient #16 back. He also stated Patient #16 did not meet admission criteria for the hospital
associated with the SNF.

The LSW was interviewed on 1/25/17 beginning at 2:08 PM. He stated Patient #16 was brought to the hospital by the Administrator of the SNF who asked for psychiatric hospitalization . He stated a psychiatrist reviewed the case and stated Patient #16 was appropriate for care at a geriatric psychiatric hospital. He stated Patient #16 was medically cleared. He stated he made multiple inquiries of psychiatric hospitals for possible admission. He stated they either did not have staffing, were on divert, or Patient #16 did not meet criteria for admission at their hospital because of his medical condition.

The LSW stated he was in a meeting when he received a call telling him Physician A had ordered ambulance transfer for Patient #16 to the SNF. He stated Patient #16 was already gone when he received the call. He stated he was not involved in the process to send Patient #16 to the SNF. He stated he communicated with nurse, charge nurse, and physician and told them the SNF would not accept the patient.

The LSW stated Patient #16 was transported by ambulance to the SNF, where the patient was refused admission. He stated the SNF did allow ambulance personnel to bring Patient #16 into the building for shelter while the ambulance staff tried to figure out placement. The LSW stated Patient #16 was eventually taken back to the ED where he waited until a different ambulance was summoned to take him to the critical access hospital.

The ED Charge Nurse on duty the morning of 1/05/17 was interviewed on 1/26/17 beginning at 11:50 AM. He stated he called the SNF to give them report on Patient #16. He stated he did not speak with a nurse at the SNF. He stated he left a message with someone that the ambulance was on the way. He stated he did not know who he left the message with.

Hospital security logs documented Patient #16 was transported from the ED to the SNF at 1:01 PM. The logs stated he returned to the ED triage area at 3:47 PM. He was transported to the critical access hospital at 5:26 PM.

Patient #16 required psychiatric treatment. Patient #16 was discharged without receiving such treatment. Instead he was sent to a SNF that had stated they would not take him back. The hospital ignored the direction of the receiving facility. This resulted in a very debilitated patient being confined to a stretcher for hours while placement was determined. It also resulted in the local ambulance and personnel being unavailable for service while placement was determined. The hospital failed to meet Patient #16's emergency needs.

2. Patient #6 was an [AGE] year old male who (MDS) dated [DATE] at 11:12 PM. The physician note, dated 1/12/17 at 5:17 PM, stated Patient #6 presented for evaluation of abdominal pain. The note stated "Maximum severity of symptoms severe. Currently symptoms are severe...Symptoms are worsening." The diagnosis was gallstones. A physician note, dated 1/12/17 at 5:17 PM, stated "Patient having history of cholelithiasis. Is transferred to [another town] for definitive care." A physician note, dated 1/12/17 at 5:23 PM, stated "Disposition Transport: Ambulance. Condition: Stable. Patient left the department."

The physician documentation did not include contact with the receiving hospital. The physician documentation did not state which physician was accepting Patient #6 at the receiving hospital. The physician documentation did not state whether the receiving hospital had the capability to treat Patient #6. Also, Patient #6's record did not contain documentation that he consented to the transfer.

Patient #6's medical record stated he (MDS) dated [DATE] at 1:12 PM. Patient #6's medical record stated he was triaged on 1/12/17 at 1:27 PM. The triage did not include a set of vital signs. Patient #6 was assigned an ESI triage level 3. The first set of vital signs for Patient #6 were taken at 2:45 PM, 1 hour and 33 minutes after he presented to the ED and 1 hour and 18 minutes after he was triaged.

Patient #6's blood pressure was 209/79 at 2:45 PM. His blood pressure was taken 5 more times, remaining high with a mild decline to 180/74 at 4:50 PM. His final blood pressure was taken at 5:22 PM. It had fallen to 109/89 at that time. Patient #6's systolic blood pressure was 100 points lower than his first blood pressure. No assessment of Patient #6 was documented at 5:22 PM or later. The time Patient #6 left the hospital was not documented.

Patient #6's Physician was interviewed on 1/25/17 beginning at 1:15 PM. He stated he diagnosed Patient #6 with a stone in the common bile duct. He stated the only physician in the area who performed the surgery was at the other hospital. He stated Patient #6 was transferred to the other hospital for surgical evaluation. He stated he thought he might have spoken to the hospitalist at the receiving hospital about Patient #6, but he stated there was no documentation in the record about this. He stated there was no documentation of any reaction to Patient #6's final low blood pressure.

3. Refer to A1104 as it relates to the failure of the hospital to ensure policies and procedures were updated and monitored and enforced on an ongoing basis.

4. Refer to A1111 as it relates to the failure of the hospital to ensure emergency services were supervised by a member of the medical staff.

The cumulative effects of these negative systemic practices seriously impeded the ability of the hospital to meet the needs of energency patients.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, staff interview, and review of medical records and policies, it was determined the hospital failed to ensure policies and procedures regarding emergency service and the department were established, followed, and monitored on an ongoing basis by the medical staff. This directly affected the care of 10 of 32 patients (#1, #5, #7, #9, #15, #20, #21, #23, #28, and #32), whose records were reviewed and had the potential to affect all patients coming to the ED. This impeded the ability of the ED staff to provide safe and consistent quality care to patients who received treatment and services in the ED. Findings include:

1. A hospital policy "Policy Development, Review, Distribution," revised 4/14, stated "Center wide policies and procedures are reviewed periodically (two years is suggested) and revised as necessary." The policy additionally stated "Each department is responsible for review and maintenance of its own internal departmental policies and procedures. Department Directors are responsible for the periodic review and updating of Center wide policies and procedures as they are department-indicated via the corporation and cost center number on the Center wide policy." This policy was not followed.

A request was made during the entrance conference for a table of contents for policies related to emergency services and the ED. The table of contents was received on 1/23/17 at 3:20 PM. The table of contents included the policy title, the date the policies were originated, and the date/dates each policy was reviewed.

There were 28 policies listed specific to the ED. Of those 28 policies, there was no documentation, in the table of contents, that 16 of the policies were reviewed since their origination date. Ten of the policies were reviewed one time. Twenty of the policies originated in the 1980's and 1990's.

However, when copies of policies for the ED were requested for review the revision dates did not match what was documented in the table of contents. Additionally, 2 of the policies requested, "Vital Signs-Emergency Department" and "Trauma I/Trauma II", were not included in the policy table of contents for the ED.

The copy of the policy "Initial Assessment, Treatment & Referral," had an origination date of 12/90 and a revision date of 1/08. The table of contents documented this policy's origination date was 12/90, but the last review date was 2001. The copy of the policy "Vital Signs-Emergency Department," had an origination date of 9/84 and the last revision was 9/08.

Policies for the ED were not updated in a timely manner or on a regular basis. Additionally, they were not monitored on an ongoing basis to ensure they were appropriate and followed current standards of practice.

The ED Medical Director was interviewed at 10:26 AM on 1/25/17. He stated policies were reviewed and updated "as best as we can." The ED Medical Director stated he spent 15 to 20 percent of his time on administrative duties. He stated he relied on the ED Director to alert him to issues in the department.

The ED Director was interviewed at 2:20 PM on 1/26/17, regarding the department policies. She confirmed the above noted policies were not updated on a regular basis. She stated she was currently reviewing the policies for any needed updates and revisions.

The policies and procedures for the ED were not reviewed or monitored on an ongoing basis, and were not revised as necessary.

2. The policy "Suicide Risk Assessment - Identifying Patients at Risk," revised 8/14, stated the purpose of the policy was to provide guidelines for identifying patients who were at risk for suicide. It stated "During the Emergency Department triage, the initial assessment, or the initial contact with the patient, nursing personnel identify those patients who are at risk for suicide and provide for patient and staff safety." The policy stated if the patient has any risk factors listed in the policy, answers yes to any of the screening questions, or if the family states the patient has a suicide plan, or the patient declines or refuses to answer questions, then the suicide precaution safety plan is initiated. The policy did not list different levels of risk, i.e. moderate or severe suicide risks.

The same policy stated the suicide precaution safety plan included notifying the house supervisor if a patient required a 1:1, and documentation of the presence of a 1:1 in the patient's room. If the patient was not on a 1:1, they were observed by staff every 15 minutes.

Another policy "One-on-One Patient Sitters," revised 10/15, stated the definition for 1:1 sitters was "Personnel, trained volunteers or family members designated to closely watch and monitor patients under the supervision of nursing staff in situations that have a high risk of patient harm." The policy further stated "Family members and trained volunteers acting as one-on-one patient sitters receive verbal instructions from the nurse on the use of the call button, a written handout related to patient safety, and will be relieved at least every two (2) hours by the nurse caring for the patient." These policies were not followed. Examples include:

a. Patient #1 was a [AGE] year old male admitted to the ED at 12:37 PM on 1/13/17. Patient #1 was not seen by a physician in the ED.

A nursing note, on 1/13/17 at 12:42 PM, stated Patient #1's main complaint was suicidal ideation. The note stated "SUICIDE RISK SCREENING: Suicide precautions, 1:1, and consult considered for suicidal thoughts or behaviors, Suicide precautions, 1:1, and consult considered for past suicidal attempts, Suicide precautions, 1:1, and consult considered for current wish to die, Behavioral Health Team Consulted, 1:1 Not Initiated, Notes: Parents at bedside [sic]." A nursing note at 1:10 PM stated the hospital's security department was notified Patient #1 was on suicide precautions. The same note stated Patient #1 was in a "video monitored room." The same note stated Patient #1 was a "Moderate risk" for suicide. The record did not explain what this meant.

Patient #1's record on 1/13/17 included documentation of 15 minute nursing checks at 1:27 PM, 1:50 PM, 2:08 PM, and 2:29 PM. At 3:01 PM the RN documented the patient was "no longer at the bedside." The circumstances surrounding Patient #1 leaving were not documented, i.e. it was not clear how he left undetected if he had 1:1 supervision and was being monitored via video. There was no documentation of attempts to locate Patient #1.

The 15 minute checks were documented at 1:27 PM, 1:50 PM, 2:08 PM, and 2:29 PM. These checks were greater than 15 minutes apart. At 3:01 PM, 30 minutes after the last check, the RN documented Patient #1 was "no longer at the bedside." There was no documentation in Patient #1's record of 1:1 monitoring.

b. Patient #20 was a [AGE] year old male who presented by private vehicle to the ED at 1:22 PM on 10/20/16, for possible overdose. A "TRIAGE" note by the RN, dated 10/20/16 at 1:27 PM, stated Patient #20's complaint was an overdose. The note stated he took Xanax, muscle relaxers, marijuana, and possibly 2 other unidentified drugs. The note did not state how much of each drug Patient #20 took or when he took them. The note did not state whether Patient #20 was suicidal or how he came to take the drugs. There were no documented vital signs. Patient #20 was triaged as a level 3 by the RN. There was no documentation how the nurse came to this decision.

A discharge note by the RN, on 10/20/16 at 1:47 PM, stated "Patient states that he is not going to wait any longer and is leaving...Patient refuses to stay..." Patient #20 was allowed to leave. No documentation was present that the nurse attempted to determine what Patient #20 ingested or whether he was a danger to himself. A nursing note stated he left at 1:51 PM. He was not seen by a physician.

c. Patient #5 was a [AGE] year old female admitted to the ED at 11:47 AM on 1/13/17, for suicidal ideation and depression. The RN documented, at 11:50 AM, Patient #5 required suicide precautions, which included a 1:1 and BHAT consultation, and the precautions were initiated.

However, there was no documentation in the record of a 1:1 sitter in the ED room. Additionally, 15 minute checks did not start until 1:20 PM, 1 hour and 30 minutes after suicide precautions were documented as initiated.

d. Patient #15 was a [AGE] year old male admitted to the ED at 4:39 PM on 1/07/17, for suicidal ideation and auditory hallucinations. His record documented suicide precautions were initiated at 4:55 PM, including, 15 minute checks, security notification, and 1:1 monitoring.

There was no documentation in the record of 15 minute checks until 7:00 PM, 2 hours and 5 minutes after they were documented as initiated. There was no documentation of 1:1 monitoring, who was assigned to the role of 1:1, or if continuous monitoring was provided.

e. Patient #23 was a [AGE] year old female admitted to the ED at 5:10 PM on 10/11/16, for evaluation of an intentional overdose of medications. The "Suicide Risk Screening," at 5:15 PM, indicated suicide precautions were initiated which included 1:1 monitoring.

Patient #23's record included documentation family was present during 2 of her 15 minute checks, at 8:00 PM and 10:45 PM. Another documented check, at 9:00 PM, stated social work was present. However, there was no documentation of 1:1 monitoring for Patient #23. Additionally, there was no documentation the family was assigned, or accepted, the 1:1 monitoring responsibility or was given verbal and written instructions for 1:1 monitoring, in accordance with hospital policy.

f. Patient #28 was a [AGE] year old female who (MDS) dated [DATE] at 11:03 PM. She was discharged on [DATE] at 2:04 AM.

A physician note, which was not written until 11/11/16 at 7:37 PM, stated Patient #28 ingested "...several Tylenol pills and Excedrine pills and cold medicine." The note stated she was depressed and was having suicidal thoughts.

A nursing note, dated 11/10/16 at 11:37 PM, stated "SUICIDE RISK SCREENING: Suicide precautions, 1:1, and consult considered for suicidal thoughts or behaviors." This indicated a person was assigned to monitor Patient #28 on a continuous basis to prevent her from harming herself. However, there was no documentation that anyone supervised her on a continuous basis. The only nursing notes in the record were a triage note on 11/10/16 at 11:18 PM, nursing assessments on 11/10/16 at 11:37 PM-11:41 PM, and a discharge note on 11/11/16 at 2:04 AM. No other nursing notes documented supervision of Patient #28.

The ED Director was interviewed on 1/26/17 beginning at 3:00 PM. She stated Patient #28's medical record did not contain documentation of patient supervision. She stated she thought the EMR might automatically document the nursing order for 1:1 supervision without the nurse realizing it.

RN B was interviewed on 1/25/17 at 12:17 PM. She stated she was a staff nurse in the ED and had 7 years of experience in ED nursing. When asked about 15 minute checks and 1:1 sitters, she stated the 1:1 sitter was supposed to document the 15 minute checks in the EMR. RN A stated if a 1:1 was not available then the RN assigned to the room would be responsible for documenting the 15 minute checks. When asked how an RN determined whether a patient required a 1:1 sitter or 15 minute checks, she stated there was a protocol for decision making.

An observation was conducted in the ED beginning at 2:35 PM on 1/25/17. During the observation a CNA was seen sitting in the nurse's station in front of a monitor. When asked what she was viewing on the monitor she stated she was watching 2 patients in 2 different ED rooms. The ED Director was asked if the patients were supposed to be monitored 1:1 for suicide precautions. The ED Director asked the charge nurse, and confirmed the patients were on 1:1 suicide precautions.

An ED staff nurse, RN C, was interviewed at 8:20 AM on 1/26/17. When asked to describe what it meant when a patient was placed on 1:1 suicide precautions RN B stated "You have eyes on the patient."

Another ED staff nurse, RN D, was interviewed at 8:22 AM on 1/26/17. When asked to describe what it meant when a patient was placed on 1:1 suicide precautions RN C stated there should be a trained staff member in the room with the patient. RN C also stated video monitoring may be used for someone who was compliant, or may have family present. When asked who was responsible for documenting 15 minute checks in the medical record, RN C stated it was her responsibility as the nurse assigned to the patient.

The Continual Readiness Coordinator was interviewed at 2:48 PM on 1/25/17. She stated there was no protocol for how to determine whether a patient required every 15 minute checks or a 1:1 sitter. The Continual Readiness Coordinator stated she believed a 1:1 sitter was a staff member sitting in the room with the patient.

The ED Director and Continual Readiness Coordinator were interviewed beginning at 2:20 PM on 1/26/17. When asked about video monitoring of patients in the ED, as part of monitoring for suicide precautions, both stated there was not a policy regarding video monitoring. When the ED Director was asked whether there was a definition of 1:1 monitoring, she stated there was not a clear definition in the policies. She also stated there were no guidelines for staff to decide when a patient needed 1:1 monitoring, 15 minute checks, or video monitoring for suicide precautions.

The ED Director reviewed the above records. She confirmed the 15 minute checks were not well documented. She stated patients left the ED when they were being monitored by staff. She also confirmed suicide precautions were not initiated when the RN documented they were. The ED Director confirmed the records with 1:1 monitoring did not include documentation of who was the 1:1 monitor or if they were present in the patient's room. She confirmed the policies were not followed for suicide precautions and 1:1 monitoring.

ED policies did not provide clear direction to staff to ensure patients were monitored and supervised until it was determined they were not a danger to themselves.

3. A policy "Triage of Patients Presenting to Emergency Department," revised 4/11, stated the purpose of the policy was "To provide a standardized system whereby patients presenting to the Emergency Department are treated in order of priority based upon acuity utilizing the Emergency Severity Index (ESI) Five-Level triage system ..." The policy stated patients arriving to the ED will be triaged to identify life-threatening conditions and priority according to their acuity. "When obtaining chief complaint, vital signs are not required unless the information is necessary to determine acuity category."

The ESI Triage website, accessed 2/02/17, stated the ESI is used for ED triage to rate patient acuity, from level 1 (most urgent) to level 5 (least resource intensive). The Agency for Healthcare Research and Quality (AHRQ) website, accessed 2/02/17, stated "The purpose of triage in the emergency department (ED) is to prioritize incoming patients and to identify those who cannot wait to be seen." A level 1 patient requires immediate lifesaving interventions, meaning they could die without immediate care. Level 2 patients are considered unable to wait for any length of time in the waiting room. Examples of a level 2 patient would be active chest pain, signs of a stroke, or a suicidal patient. For levels 3, 4, and 5 the triage nurse identifies how many resources may be needed and whether the patient's vital signs are in a "danger zone" or of concern.

The ESI algorithm uses four decision points to sort patients into one of the five triage levels. "The four decision points depicted in the ESI algorithm are critical to accurate and reliable application of ESI. The figure shows the four decision points reduced to four key questions:

A. Does this patient require immediate life-saving intervention?

B. Is this a patient who shouldn't wait?

C. How many resources will this patient need?

D. What are the patient's vital signs?"

By answering the questions, the triage nurse will be guided to the appropriate triage level.

The hospital policy and ESI triage algorithm was not followed, to prioritize and sort patients who presented to the ED, according to their acuity level. Examples include:

a. Patient #20 was a [AGE] year old male who presented by private vehicle to the ED at 1:22 PM on 10/20/16, for possible overdose. A "TRIAGE" note by the RN, dated 10/20/16 at 1:27 PM, stated Patient #20's complaint was an overdose. The note stated he took Xanax, muscle relaxers, marijuana, and possibly 2 other unidentified drugs. The note did not state how much of each drug Patient #20 took or when he took them. The note did not state whether Patient #20 was suicidal or how he came to take the drugs. There were no documented vital signs. Patient #20 was triaged as a level 3 by the RN. There was no documentation how the nurse came to this decision. There was no documentation that the nurse asked Patient #20 if he was suicidal.

A nurse's note at 1:47 stated "Patient [#20] states that he is not going to wait any longer and is leaving. Patient and family told that another patient is being discharged and as soon as the room is cleaned we will put him in it. Patient refuses to stay, sons unable to talk patient into staying. Patient ambulated out to personal vehicle. Told sons that if patient changes his mind they are welcome to come back."

b. Patient #21 was a [AGE] year old female who presented by private vehicle to the ED at 4:44 PM on 10/28/16, for a mental health evaluation. Patient #21 was triaged as a level 3 by an RN at 5:04 PM and was sent to wait for an available bed. The RN documented Patient #21 was not suicidal, however no vital signs were documented in triage. At 5:54 PM, 50 minutes after triage, Patient #21 was placed in ED room 15 and her vital signs were obtained.

c. Patient #9 was a [AGE] year old female who presented by private vehicle to the ED at 1:34 PM on 12/20/16, for shortness of breath. Patient #9 was triaged as a level 3 by the RN at 2:12 PM, 38 minutes after coming to the hospital. Patient #9 was sent to wait for an available bed. There was no documentation of vital signs in triage. Patient #9's first vital signs were documented at 2:16 PM.

d. Patient #7 was a [AGE] year old male who presented by ambulance to the ED at 1:22 PM on 1/11/17, for chest pain. Patient #7 was triaged as a level 3 by an RN, and sent to wait for an available bed. There was no documentation of vital signs in the record although an EKG was documented at 1:33 PM. At 3:09 PM, 1 hour and 47 minutes after his arrival, another RN documented "Attempted to place pt [patient] in room, pt refused further care, refused to be seen in ER and claims would remains [sic] at bedside of wife in other ER room."

8. Patient #32 was a [AGE] year old male who was brought to the ED by police at 12:55 AM on 1/25/17 for suicidal ideation. A nursing note at 12:55 AM stated Patient #32 was anxious and agitated. The note stated was very angry with the police and would be violent toward them if they "come at me." Patient #32 was triaged at 12:58 AM as a level 4 by an RN. Patient #32 should have been triaged as a level 2 according to the ESI model because of the potential severity of his symptoms and the threat to the safety of himself and others.

During an interview beginning at 2:20 PM on 1/26/17, the ED Director and Continual Readiness Coordinator reviewed the policies and the ED records. The ED Director stated it was her belief patients required an acuity level in order to "move them in our system." She confirmed vital signs were not always obtained prior to assigning patients an acuity level. She reviewed the above medical records. The ED Director confirmed staff did not follow the ESI algorithm.

The hospital policy for triaging patients in the ED was not followed.
VIOLATION: SUPERVISION OF EMERGENCY SERVICES Tag No: A1111
Based on staff interview and review of meeting minutes and administrative documents, it was determined the hospital failed to ensure emergency services were supervised by a member of the medical staff. This resulted in a lack of direction to ED staff. Findings include:

ED Medical Staff meeting minutes were requested for the past 2 years. Three meetings were documented in 2015. Two meetings were documented in 2016, on 1/19/16 and on 4/12/16. No meetings were documented since 4/12/16.

Documentation was present that the ED Medical Director reviewed 10 grievance cases in 2016. Documentation was present that he responded to some emails on behalf of the ED. No other documentation was present to show the ED Medical Director supervised emergency services.

The Medical Director for the ED was interviewed on 1/25/17 beginning at 10:30 AM. He stated the Medical Staff review policies and updated them as best as they could. He stated he relied on Nursing Director to alert him to issues. He stated 80 percent of his time was devoted to clinical activities. He stated he worked shifts seeing patients in the ED. He stated spent 15-20 percent of his time on administrative matters. He stated he did not keep a record of his time performing administrative tasks for the ED. He stated he did not keep a record of what tasks he performed for the ED.

The hospital did not maintain evidence that the ED Medical Director supervised emergency services at the hospital.