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.

Based on tour of the Emergency Department, it was determined that the facility did not integrate essential activities as demonstrated by the failure to maintain refrigerators in proper working order to ensure patient safety.

Findings include:
During a tour conducted of the Psychiatric and Adult Medicine Emergency Department on 1/23/12 at 10:30AM with the ED Director of Nursing it was noted that:

The facility did not monitor the operation of pantry refrigerators as these were not working effectively.
Patient snacks and food items were not properly labeled and stored.
Foods intended for patient consumption were kept in soiled and unsanitary refrigerators.

The following was observed:

1. The pantry refrigerator at the Psychiatric Emergency Department was dirty and had dried food stains in the plastic food bins. The plastic enclosure inside the door of the refrigerator had an open crack. There were three sandwiches in the food bin. One was labeled with a date, and the other two sandwiches had no label of any kind. These three patient sandwiches were wrapped in plastic film and contained an unidentified white meat.
There was an employee sandwich half eaten wrapped in aluminum foil in the refrigerator. An uncovered bin with melting ice was stored in the refrigerator. The ice machine located in both the Adult and Psychiatric ED pantries did not work.

2. Temperature logs for this refrigerator were reviewed. The January 2012 log contained six temperature readings that were above 42 degrees Fahrenheit. In December 2011, there were 3 readings above 42 degrees Fahrenheit and one of the readings was as high as 48 degrees. The above temperatures do not meet dietary standards for food safety. In addition, when staff was asked what was the process they used when temperatures were out of range, a PCT informed the surveyor they call Engineering and wait for it to be fixed. There was no evidence in any of the temperature logs that Engineering checked and performed maintenance on both refrigerators. On the bottom of the form is a section for the Engineering Department to complete when temperature is out of range.

3. The pantry refrigerator at the Adult Medicine Emergency Department had dirt
stains inside of the refrigerator. The freezer had no door but had extreme build-up of ice. Three cold compresses were stored in the freezer compartment of the refrigerator. Milk cartons (3 half gallons) were stored at the bottom of the refrigerator. Two patients' breakfast plates containing scrambled eggs and biscuit were found stored in the pantry cabinet. The top panel of the interior of the microwave used to reheat meals was stained black.
The ED Director of Nursing who was present during the tour touched the black discoloration with her hands and stated the plastic was deteriorating. There was no evidence documented that the microwave oven was routinely inspected.

A. Based on the review of medical records, it was determined that the facility failed to implement its policy on "Walk-Out/AMA".

Findings include:

Fourteen out of twenty five medical records reviewed had no nursing documentation of patient walk outs, notification attempts, time of discovery, or efforts made to locate the patient as per hospital policy.

The review of records on 01/24/12 with the ED Nurse Manager noted that the ED policy on Walk-Out/AMA was not consistently implemented. The policy notes that when a patient is no longer in the emergency department during the evaluation process, the patient will be deemed a "Walk-Out". Three separate notifications will be attempted and documented in the medical record within 15 minute intervals before the patient's chart is removed from the tracking board.

Examples include:

A1. MR # 1 for [AGE] year old male who (MDS) dated [DATE] with breathing difficulty did not contain documentation of a written medical assessment. The record noted the patient presented with difficulty breathing at 1719 and was triaged at 1720 (5:20PM) as triage category, ESI level 2. The status event section of the record noted that the patient was with the doctor at 1914 hours and at 1917 noted "MD request departure". At 1919, the patient was noted in sonogram and that the patient departed at 1919. A nursing departure assessment, recorded at 1914, referenced vital signs taken, and under a section for discharge verification, there was a notation of provision of written instructions. Follow-up documentation provided by the facility noted the patient's disposition as "walk out, condition stable", and was written with a different departure time of 2359 (11:59PM). No medical or nursing note was evident to explain the reason for the discrepancy in the medical record about the disposition of discharge or walk out. No documentation was present to explore the reason for the walk out.

At interview with IT staff on 1/24/12, staff was unable to explain why the record contained documentation of discharge contrary to supplemental computerized information reportedly entered by a clerical staff member noting that the patient had walked out.

A2. MR #3 for a [AGE] year old male who presented on three separate occasions to the ED on 10/17/11 with the same complaints of chest pain failed to include documentation for walk-outs in accordance with the facility's policy.

The patient walked out before medical assessments were provided during the first two encounters and there was no documentation of the circumstances surrounding these walk outs.

During visit #1, the patient presented at 0647 AM on 10/17/11 with chest pain and was triaged as a category ESI level 3 at 648AM. ED departure information in the record noted the patient left "AMA" at 0823 AM on 10/17/11. There was no evidence of attempts to explain why the patient left AMA or effort to counsel the patient about the risks of departure against medical advice.

A second emergency medical record for this patient found that the patient was again triaged at 8:13 AM on 10/17/11 for chest pain . The status event history noted the patient was registered at 8:29 AM and then departed at 1912 (7:12PM). Again there was no documentation to explain why the patient walked out.

The patient presented to the ED with chest pain in a third encounter at 1545 (3:45PM) on 10/17/11. The patient was triaged as ESI 3 and the nurse noted that the patient was "complaining of chest pain since early this AM, patient was in the ED for said symptom and stated he walked out". On this occasion the patient was seen and assessed by the MD.

Although the ED log for the first ED encounter noted the patient had left AMA, there was no evidence the facility implemented its policy for AMA's and walk outs during the patient's first two ED visits on 10/17/11.

Similar findings related to the lack of implementation of facilty's policy on walk outs were noted in MR #s 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, and 15.

B. Based on review of records and staff interviews, it was determined the hospital did not implement effective procedures that ensures inclusion of necessary documentation, in order to conform to standards of emergency care.

Findings include:

Review of 1 of 6 applicable medical records on 1/24/2012 found missing elements of documentation, including sonogram test results, from a patient record.

MR #2 for a [AGE] year old pregnant female at 7.5 months gestation who (MDS) dated [DATE] with complaints of pain in the lower back did not contain documented results of a sonogram, or fetal heart monitor prior to transfer to another acute care facility. The patient was triaged at 1528 (3:28 PM) as a level 3 ESI triage category. Nursing note at 1628 indicated there was no fetal monitor in the ED and that the MD had been notified who would have a sonogram done on patient to obtain fetal heart rate. The patient was seen by the MD at 1657 (4:57PM) and lab work was ordered at 1659. At 1807 hours, the nurse noted there was no fetal heart monitor available in ED and the MD and nurse were notified. Sonogram was retrieved from the floor . The MD was made aware that the sonogram was in the ED and there was no new order. The patient was transferred to another hospital by ambulance. There was no evidence of any documented sonogram results in the record.

At interview with the Chairman of the ED and Nursing ED Director on 1/24/2012, it was stated that there is always a fetal heart monitor machine available in the ED, that a sonogram machine is currently shared with the intensive care unit staff, and that new machines dedicated to each unit are on order. It was also stated the sonogram should have been completed and that the transfer to another hospital could not have been effectuated unless the results of the sonogram were provided. Staff reported it must have been completed and would check into this matter further. However, review of the inter-institutional transfer documentation did not include the results of the sonogram.

C. Based on tour of the Adult Emergency Department, it was determined that the facility did not ensure the identification of all hospital personnel through the use of identification name tags which are clearly visible and are worn at all times.

Findings include:

During the tour conducted in the Adult Medicine Emergency Department it was observed that two physicians sitting in front of computers situated in the Nurses' Station were not wearing identification tags. Another physician that passed by the surveyor was also not wearing an employee ID tag. It was stated at interview with other staff on 1/23/12 that these unidentified employees were physicians.