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.

NOVANT HEALTH THOMASVILLE MEDICAL CENTER 207 OLD LEXINGTON RD BOX 789 THOMASVILLE, NC 27360 May 19, 2016
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on hospital policy and procedure reviews, medical record reviews, specialty physicians on-call list reviews, physician and staff interviews, the hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice for 2 of 25 patients who presented to the hospital's dedicated emergency department for evaluation and treatment of an emergency medical condition (#13 and #4).

Findings included:

The hospital's Dedicated Emergency Department (DED) physician failed to provide a Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed; and/or failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 2 of 25 sampled patients (#13, and #4) who presented to the hospital's DED for evaluation and treatment of an EMC and were discharged .

~ cross refer to 482.55(a) Organization and Direction - Standard Tag A1101.
VIOLATION: ORGANIZATION AND DIRECTION Tag No: A1101
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy and procedure reviews, medical record reviews, speciality physicians on-call list reviews, physician and staff interviews, the hospital's Dedicated Emergency Department (DED) physician failed to provide a Medical Screening Examination (MSE) within the capability of the hospital's DED, including ancillary services routinely available to the DED, to determine whether or not an Emergency Medical Condition (EMC) existed; and/or failed to provide within the capabilities of the staff and facilities available at the hospital, for further medical examination and treatment as required to stabilize the medical condition for 2 of 25 sampled patients (#13, and #4) who presented to the hospital's DED for evaluation and treatment of an EMC and were discharged .

Findings included:

Review on 05/17/2016 of current hospital policy "EMTALA", NH-PC-CC-1132, revised July 2013, revealed "...II. POLICY It is (Hospital A's) policy to provide care to individuals who come to the dedicated emergency department or present elsewhere with an emergency medical condition in a manner that best meets the needs of those individuals and that complies with applicable state of federal laws. ...A. Medical screening examinations 1. Individuals (including minors) entitled to a medical screening examination ...a) Individual's in the dedicated emergency department (ED) seeking medical care - When an individual comes to the dedicated emergency department of the hospital, and a request is made on the individual's behalf for a medical examination or treatment, the hospital shall provide for an appropriate medical screening examination within the capability of the hospital's emergency department, to determine whether an emergency medical condition exists. ...2. Scope of the medical screening examination a) A medical screening examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. The hospital shall apply in a non-discriminatory manner (i.e. a different level of care must not exist based on payment status, race, national origin, etc.) a screening process that is reasonably calculated to determine whether an emergency medical condition exists. The medical screening examination shall include both a generalized assessment and a focused assessment based on the individual's chief complaint, with the intent to determine the presence or absence of an emergency medical condition. Depending on the individual's presenting symptoms, the medical screening examination may range from a simple process involving only a brief questioning and examination for individuals who come to the facility for non-emergency services to a complex process that also involves performing ancillary studies and procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans and other diagnostic tests and procedures. b) All individuals coming to the emergency department shall be provided a medical screening examination beyond 'login' and initial triage. ...C. Stabilization of individuals in the dedicated emergency department who have an emergency medical condition 1. General standards - Individuals in the dedicated emergency department who have an emergency medical condition shall receive necessary stabilizing treatment or an appropriate transfer to another medical facility. 2. Stable for transfer - An individual in the dedicated emergency department whose emergency medical condition has not been resolved may be stable for transfer from one facility to another facility if the treating physician has determined, within reasonable clinical confidence, that the individual is expected to leave the hospital and be received at the second facility with no material deterioration in his or her medical condition and the treating physician reasonably believes that the receiving facility has the capability to manage the individual's medical condition and any reasonable foreseeable complication of that condition. ...4. Stable for discharge - An individual is considered stable for discharge when, within reasonable clinical confidence, it is determined that the individual has reached the point where his/her continued care, including diagnostic work-up and/or treatment, reasonably could be performed as an outpatient or later as an inpatient, provided the individual is given a plan for appropriate follow-up care with the discharge instructions. ...VII. DEFINITIONS ...Capabilities - of a medical facility means that there is physical space, equipment, supplies and services....including ancillary services, that the facility provides. The capabilities of the facility's staff means the level of care that the hospital's personnel can provide within the training and scope of their professional licenses. ...Capacity - the ability of the hospital to accommodate the individual requesting examination or treatment... Capacity encompasses number and availability of qualified staff, beds, equipment... Comes to the emergency department - means with respect to an individual who is not a patient, the individual - 1. Has presented at a hospital's dedicated emergency department....and requests examination or treatment for a medical condition, or has such a request made on his or her behalf. ...Emergency medical condition - a medical condition manifesting itself by acute symptoms of [DIAGNOSES REDACTED]. Serious impairment to bodily functions, or 3. Serious dysfunction of any bodily organ or part ...Stabilized - with respect to an emergency medical condition means that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from the facility....A patient will be deemed stablized if the treating physician of the individual with an emergency medical condition has determined, within reasonable clinical confidence, that the emergency medical condition has been resolved. To stabilize - means with respect to an emergency medical condition to provide such medical treatment of the condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility..."





1. Hospital A, closed DED record review on 05/18/2016 for Patient #13, revealed a [AGE] year old female (MDS) dated [DATE] at 0312 (Visit #1) for an arrival complaint of "Abdominal pain and Headache." Review revealed at 0313 the patient was placed into treatment room #10. Review of an ED flowsheet revealed arrival vital signs were assessed as Heart Rate (HR) 64, Respirations (R) 20, Blood Pressure (BP) 132/82, Oxygen Saturation (SpO2) 100% and Temperature (T) 98.7 Fahrenheit (F). Review revealed a Medical Screening Exam (MSE) was initiated at 0317 by Physician B. Review of ED Notes by a Registered Nurse (RN) at 0320 revealed "Pt states that she has had severe abdominal pain and headache since 4pm yesterday. The pain starts just below her breasts and overs her entire abdomen. Her pain in her head is on the right side, the vision to the right eye is blurry, and she says that the right side of her face is numb and her smile appears not to be symmetrical." Review revealed at 0323 CT (computed tomography) BRAIN HEAD WO (without) CONTRAST was ordered. Review of a Focused Assessment at 0327 documented by a RN revealed, "...Sudden Onset of Severe Headache?: Yes ...Glasgow Coma Scale Score: 15 (normal)..." and at 0332, "Vision Assessment: R (right) eye: Blurred; L (left) eye: intact." Review revealed at 0338 Morse Fall Risk Score: 45 (0: No risk for falls, <25: Low Risk, 25-45: Moderate Risk, >45 High Risk). Review at 0340 of a "Stroke Screen Tool" revealed, "Facial Droop present?: Yes, Arm Drift Present?: No, Ataxia Present?: No, Slurred Speech/ Unable to Speak?: Yes, Worst Headache of Their Life?: Yes, Date Last Known Well: 10/05/15, Time Last Known Well: 1600, Symptoms Date: 10/05/15, Onset of Symptoms: 1600." Review revealed at 0340 the patient was triaged as a priority 3 (Emergency Severity Index 1-5, 1 most severe, 5 least severe).

Review revealed at 0340 the following lab and medication orders placed for: SALICYLATE LEVEL, ACETAMINOPHEN LEVEL, ETHANOL, UR (urine) DRUGS OF ABUSE SCRN (screen), URINALYSIS WITH MICROSCOPIC, COMPREHENSIVE METABOLIC PANEL, CBC (complete blood count) AND DIFFERENTIAL and Toradol (nonsteroidal anti-inflammatory medication) injection 60 mg (milligrams).

Review revealed CT exam started at 0408 and resulted at 0436 with "IMPRESSION: Multiple hypodensities in the right hemisphere, involving the cerebellum, frontal and parietal lobes, these are nonspecific. MRI (Magnetic Resonance Imaging) could better evaluate for infarction or other etiology such as infection or neoplasm. Consider follow up MRI with and without contrast." Review revealed MRI BRAIN WO W CONTRAST ORDERED and CT SCAN ABDOMEN PELVIS W CONTRAST ordered at 0442.

Review revealed at 0449 Critical Result Report called of WBC (White Blood Cell count) Test Result: 1.24 [ref. range 3.7 - 11.0]. At 0531 Critical Result Report Called for Potassium Test Result: 2.2 [ref. range 3.7 - 5.4].

Review revealed 0553 CT scan of abdomen started and final results at 0636 with "IMPRESSION: Large-volume of abdominal and pelvic ascites. No acute finding in the abdomen or pelvis."

Review of MSE documentation by Physician B dated 10/06/2015 at 0507 revealed, "Chief Complaint: Patient presents with Abdominal Pain; Headache (recurrent or known dx [diagnosis] migraines) Patient is a 55 y.o. (year old) female presenting with headache. History provided by: Patient; Headache (New onset or symptoms) Pain location: generalized; Quality: Dull; Radiates to: Does not radiate; Severity currently: 6/10; Severity at highest: 6/10; Onset quality: Gradual; Timing: constant; Progression: worsening; Chronicity: new; Similar to prior headaches: no; Context comment: Also has abdominal pain and weight loss; Relieved by: nothing; Worsened by: nothing; Associated symptoms: no cough, no dizziness, no fever, no nausea, no sore throat and no vomiting. Patient with complaint of headache and abdominal pain for several days she's had these complaints for some time it's been worse over the last several days he [sic] also has approximately 30 pound weight loss over the last few months she is a heavy drinker of alcohol. Review of Symptoms: Neurological: Positive for headaches. Negative for dizziness and seizures. Physical exam: Constitutional: She is oriented to person, place and time. She appears well-developed and well nourished. She is active. Emaciated HENT (head, eyes, nose, throat): Head: Normocephalic and atraumatic. Eyes: Pupils are equal, round and reactive to light. Neck: Normal range of motion, full passive range of motion without pain and phonation normal. Neck supple. Cardiovascular: Normal rate, regular rhythm, normal heart sounds and intact distal pulses. Pulmonary/Chest: Effort normal and breath sounds normal. Abdominal: Normal appearance and bowel sounds are normal. There is tenderness. Nonfocal tenderness ...MDM (Medical Decision Making) Number of Diagnosis or Management Options: Diagnosis management comments: IV fluids IV analgesics and antiemetics given CT of the head revealed multiple hypodensities consistent with metastases ordered MRI at radiology's recommendation and also abdominal CT given the findings. Signed out to (Physician A) at 7AM for further results and disposition."

Review of an ED Progress Note by Physician A at 0701 revealed, "Assumed care of the patient from (Physician B). Please refer to his note for the history of the present illness and review of symptoms together with the clinical exam." Review revealed no available documentation of physical exam reassessment of the patient by Physician A after assuming care from Physician B.

Further record review revealed the patient was transported to MRI at 0716 and returned at 0804. Review revealed MRI Final Result at 0816 "IMPRESSION: 1. Infarcts of differing ages in the posterior circulation with acute/subacute infarcts in the cerebellar hemispheres bilaterally and older infarcts in the left hemisphere, right thalamus, and bilateral occipital lobes. 2. Mild chronic ischemic changes in the periventricular white matter."

Review revealed at 0951 the patient's disposition was set to discharge by Physician A. Review revealed a final diagnoses, "Nonintractable headache, unspecified chronicity pattern, unspecified headache type; Abdominal pain, unspecified abdominal location and Alcohol Abuse." Review revealed written discharge instructions for Abdominal pain, Headache and Alcohol Abuse and prescriptions for K-Dur 20 meq tablets and Fioricet (pain medication) 50-325-40 mg per tablet and verbalized understanding of given information.

Review of a Progress note at 0955 by Physician A revealed "Reviewed the MRI results with the patient. Also went over the lab results as well as the CT that was already discussed by Physician B. I strongly counseled on avoiding alcohol as well as NSAIDs (non-steroidal anti-inflammatory medications). I will give her Fioricet for her headaches. Advised her to start taking an aspirin daily. 2 [sic] follow up with a primary care provider as soon as possible." Review revealed the patient was discharged home at 1008 ambulatory via cab.

Review revealed vital signs were reassessed at:
0636 - T 98.5 F, HR 105, R 18, BP 120/67, and SpO2 100%; and
0809 - HR 80, R 18, BP 118/65, and SpO2 97%.

Review revealed the following medications ordered and administered:
0351 - Toradol 60 mg IM (intramuscular) for a pain of 10 "worst pain ever" on a 0/10 scale;
0456 - IVF 0.9% Na Cl (Normal Saline) via 20 gauge IV established right forearm;
0500 - Omnipaque 50 ml (oral contrast) oral;
0509 - Zofran (antiemetic) 4 mg IV;
0541 - Demerol (pain medication) 25 mg IV for pain score 9/10; and
0925 - K-Dur 40 meq oral.

Continued medical record review revealed Patient #13 returned to Hospital A's DED on 10/11/2015 (5 days later) at 0851 (Visit #2) ambulatory via private transportation for an arrival complaint "Detox evaluation; Pt reports would like to detox from alcohol. Reports she has been drinking a pint of liquor daily since this past year." Review revealed vital signs at triage were assessed as BP 153/57, HR 100, R 18, SpO2 99% and T 97.9 F. Review revealed the patient was assigned an acuity level 3. Review revealed MSE was initiated at 0901.

Review of MSE documentation by Physician L at 0915 revealed "History: Patient reports alcohol abuse for the last 8 months. She last drank earlier today. States she wants detox from alcohol. Denies any other substance abuse. Denies suicidal or homicidal ideation. There has been no recent trauma. States feels tremulous but has no reported seizures. Was evaluated in this emergency department on 10/06/15 for chief complaint of abdominal pain and headache ...Patient is still complaining of a right-sided headache, right eye diplopia (double vision), states the symptoms have been going on for 6 days. Also complains of a right facial droop which has been present for 3 days. Denies any focal weakness but states she feels generally weak. Also states she has left-sided facial numbness. Furthermore reports that she is having trouble ambulating due to staggering and that all these symptoms have been going on for 6 days as well. Complains of lower abdominal pain which has been unchanged for the last one week. Review of Systems: Constitutional: Negative for fever, chills, diaphoresis and fatigue. HEENT: Negative for congestion, drooling, nosebleeds and rhinorrhea. Eyes: Positive for visual disturbance; Gastrointestinal: Positive for nausea and vomiting and abdominal pain. Negative for diarrhea. Neurological: Positive for dizziness, facial asymmetry, weakness, numbness and headaches. Negative for tremors, seizures, syncope and spee[DIAGNOSES REDACTED]iculty. MDM Number of Diagnoses or Management Options: Diagnosis management comments 1203 PM Care of patient discussed with radiology as well as (Physician C) of teleneurology. (Physician C) has evaluated the patient at bedside. Patient has a large right cerebellar infarct that is likely subacute. She does have edema and (Physician C) recommends admission to the hospital but has neurosurgical backup should the need for this arise. I discussed this with the patient and the patient will be transferred to (Hospital C)." Record review revealed the patient was transferred to Hospital C at 1400.

Review revealed Labs and CT of the Head ordered at 0945. Review revealed CT Scan Final Result at 1044 "IMPRESSION: Evolution of right cerebellar infarct with mild increase/mass effect. No intracranial hemorrhage identified."

Review of TeleNeurology Consult by Physician C at 1158 revealed "Notes: c/o dysmetria (uncoordination), ataxic (unbalanced), right facial droop, left facial numbness, right eye diplopia. PMH: (Past Medical History) ETOH (alcohol), HTN. Head CT 6 days ago showed subacute infarct in cerebellum. Today shows large amount of edema. Meds: no anticoagulants. NIH (National Institute of Health) Stroke Score: 6; diagnosis of [DIAGNOSES REDACTED]'d (discharged ). CT and MRI were done, suggested new cerebellar infarcts, bilat older hemispheric infarcts. She has had persistent HA, diplopia, can't drive, came back to ER; Objective: awake, alert, minimal slurring per patient, L facial droop, EOMI (extraoccular movements intact- eye muscles), but she has a vertical diplopia, no field cuts. Strength is normal in BUE (bilateral upper extremities). FTN (finger to nose) done well. RLE (right lower extremity) has mild drift. HTS (heel to shin) is symmetric. Decreased sensation L face, arm; Assessment: Evolving R cerebellar infarct, older L cerebellar infarct. ETOH abuse, smoker; Admission Recommendations: Admit patient to Telemetry or Stroke Unit."

Hospital C, closed medical record review on 05/20/2016 for Patient #13 revealed the patient was accepted for transfer from Hospital A's DED on 10/11/2015 for admission to the facility's Neurology unit with a diagnosis of [DIAGNOSES REDACTED]. MRI and CT scan on her previous visit (10/06/15) demonstrated large right cerebellar infarct without hemorrhagic conversion. Transferred to Neurology service for further evaluation. Brain scan on 10/11/15 demonstrated stable findings with minimal mass effect and no [DIAGNOSES REDACTED] ...Received bedside therapy from PT (physical therapy) / OT (occupational therapy) / ST (speech therapy) and was evaluated by inpatient rehabilitation physician, it was decided the patient will benefit from low intensity rehab therapy and she is medically stable to be discharged today. Discharge NIHSS (National Institute of Heath Stroke Scale) = 2 (minor stroke); Modified Rankin Scale: 3 (Moderate disability, requiring some help, but able to walk without assistance). Review revealed the patient was discharged to inpatient physical therapy on 10/21/2015.

Review of Hospital A's DED Specialty On-call Physicians list revealed Neurology was available on-call on 10/06/2015 during Patient #13's DED visit.

Interview on 05/19/2016 at 1445 with Physician A revealed he assumed care of Patient #13 from Physician B on the morning of 10/06/2015 when he came on shift. Interview revealed he initially thought about admitting her after review but clinically did not see any reason to do so. Interview revealed "When I saw her clinically she appeared stable that's why I discharged her. Based on my impression I was comfortable discharging." Interview revealed Physician A felt Patient #13 did not need a neurology consult based on the CT and MRI reports and gave the patient instructions to follow up the her primary care physician. Interview revealed Patient #13's emergency medical condition was resolved on discharge. Interview revealed Physician A did not document a reassessment on Patient #13 prior to discharge.

Telephone interview with Physician C on 05/19/2016 at 1630 revealed he was the consulting physician (Neurologist) for Patient #13 on her 10/11/2015 DED visit. Interview revealed when he reviewed his notes from the patient visit, Patient #13 was having "an acute stroke" on her previous ED visit (10/06/2015). Interview revealed based on patient information and presentation he would not have discharged the patient home on 10/06/2015.

Telephone interview with Physician B on 5/19/2016 at 1945 revealed he initiated the MSE and signed over care of Patient #13 to Physician A the morning of 10/06/2015. Interview revealed "she did not look good and I was not clear what was going on. Looked terrible, emaciated and thinking a differential of cancer but withholding judgment." Interview revealed neuro exam was not well documented due to electronic template and wished he had put more pertinent negative findings in there. Interview revealed after learning the MRI result, she fit the picture of what was going on. Interview revealed he felt the patient had complaints that were concerning and needed MRI result to know more. Interview revealed he left final disposition of the patient to Physician A. Interview revealed when asked, if he knew the result of the MRI while the patient was in his care, would he have discharged the patient; his response was "I would rather not answer that question."





2. Hospital A, closed DED record review on 05/18/2016 for Patient #4 revealed a [AGE] year old male presented ambulatory via private transportation to the hospital's DED on 01/04/2016 at 1517. Review of "Arrival Complaint documentation revealed the patient presented with reported "shob (Shortness of Breath)." Review of Triage documentation revealed the patient was triaged by RN #16 at 1527. Review revealed vital signs were assessed as Temperature (T) 97.2 degrees Fahrenheit, Heart Rate (HR) 98, Respirations (R) 18, Blood Pressure (BP) 132/85, Oxygen Saturation (SpO2) 99% on room air. Review revealed "Chief Complaints Updated: Shortness of Breath (reports onset of cough and shortness of breath since before Christmas). Reports he had a CT (computed tomography) of his chest today in out patient [sic]) at 1528." Review of Pivot Triage Assessment documentation by RN #16 revealed, the patient reported his pain level as "No/denies pain" (0 pain free, 5 worst pain). Review revealed the patient was triaged as a priority 3 (Emergency Severity Index 1-5, 1 most severe, 5 least severe). Review revealed the patient was placed into treatment room #7 at 1547 and assigned to RN #2. Continued review of nursing assessment documentation revealed a Glasgow Coma Scale (GCS) [used to gauge level of consciousness] Score of 15 (Severe: GCS 3-8, Moderate: GCS 9-12, Mild: GCS 13-15). Review revealed, "Level of consciousness - Oriented. Respiratory - Patient reports Shortness of breath (x1 month)." Review revealed "Bilateral Breath Sounds: Clear and equal" with "Regular breathing pattern." Review of discharge documentation revealed the patient's condition at discharge "Improved, Stable" at 1850. Discharge instructions reviewed with the patient with education material for "Embolism" provided. Review revealed at 1850, vital signs were reassessed as HR 97, R 16, BP 137/102, and SpO2 99% on room air. Review revealed a pain score: 3. Review revealed final diagnoses included [DIAGNOSES REDACTED]"

Review of Medical Screening Exam (MSE) documentation by Physician A at 1555 revealed the patient's chief complaint was "Shortness of Breath (SOB)." Review revealed the patient reported the "onset of cough and shortness of breath since before Christmas. reports [sic] he had a CT of his chest today in out patient [sic]." Review revealed, "He denies any fever or chills. he [sic] just would like to find out what's the cause of his shortness of breath." Review revealed the patient "had a CT scan as an outpatient today and he decided to come to the emergency room to get checked out to further evaluate this. The patient denies any other symptoms per say. History of pneumonia involving the right lung and this was in June 2015. Please note the patient is saturating at 99% on room air." Review revealed a "Past medical history of [DIAGNOSES REDACTED]" Review revealed the patient was followed by Physician J (Pulmonologist) on an outpatient basis. REVIEW OF SYSTEMS (ROS) revealed "Constitutional: Negative for fever. Cardiovascular: Negative for chest pain. Respiratory: Negative for shortness of breath....Neurological: Negative for headaches, weakness or numbness....PHYSICAL EXAM: VITAL SIGNS: ED Triage Vitals....Blood Pressure (BP) 01/04/2016 1528 132/85 Heart Rate (HR) 98; Respirations (R) 18; Temperature (T) 97.2 degrees Fahrenheit, SpO2 99%. Constitutional: Alert and oriented ...HEENT (Head, Ears, Eyes, Nose, Throat) Cardiovascular: Regular rate and rhythm. No murmur, Good distal peripheral pulses. Pulmonary/Chest: Normal respiratory Effort ...Neurological: Normal speech and language. No gross focal neurological deficits....Psychiatric: Normal mood and affect. Speech and behavior are normal." Review revealed "Clinical Impression: None [sic]." Review revealed, "ED COURSE: Pertinent labs & imaging results that were available during my care of the patient were reviewed by me....6:30 PM Patient follows with (Physician J) the pulmonologist. I have started the patient on anticoagulation for his pulmonary embolus. He is to follow-up with (Physician J) in 2 days. Given for [sic] Coumadin and His First Dose of Lovenox Was Given in the emergency room ."

Review of "Medications - Clinical Orders" by Physician A at 1727 revealed orders for "Lovenox (anticoagulant) injection 60 mg subcutaneously," administered by RN #2 at 1737 and "Coumadin (anticoagulant) 5 mg by mouth," administered by RN #2 at 1849. Review revealed a prescription order from Physician A at 1825 for Coumadin 5 mg tablet (3 tablets), "Take 1 tablet (5 mg total) by mouth daily."

Review of "Lab - Clinical Orders" by Physician A revealed the following labs ordered and resulted:
1. Basic Metabolic Panel "STAT" : Creatinine 1.44 [Reference Range 0.76 - 1.27];
2. ProBNP "STAT": 5982 [Reference Range: <=899];
3. PT 13.3 [Reference Range: 10.0 - 11.8];
4. INR: 1.23 [Reference Range: 2.0 - 3.0]; and
5. PTT 29 [Reference Range: 21-36].

Review of radiology report from CT scan performed in outpatient prior to DED presentation revealed, "RADIOLOGY: CT Chest W (with) Contrast: 01/04/2016 INDICATION: ...Pleural effusion, not otherwise classified ...images were obtained through the chest ...COMPARISON: CTPA date 6/1/2015 FINDINGS: ...Lungs: Moderate somewhat loculated (cavity of fluid) pleural effusions are present bilaterally (both) with or [sic] calcifications along the posterior right upper lobe and at the left lung apex. ...Glass infiltrates of both lungs with linear areas of atelectasis, scar or rounded atelectasis of the right mid to lower lung and atelectasis or infiltrate of the right lower lobe. ...Vasculature: Incidental filling defect of the posterior basal segmental [DIAGNOSES REDACTED] on the right. 01/04/2016 IMPRESSION: 1. Filling defect of a right lower lobe [DIAGNOSES REDACTED] representing pulmonary embolus. 2. Moderate loculated effusions bilaterally with pleural calcifications similar to the previous exam. This is nonspecific and can be seen with fibrotic or ileus no lung disease, [DIAGNOSES REDACTED], collagen vascular disease or early in pleural-based neoplasm. No nodularity or mass is identified to suggest neoplasm. 3. Mild groundglass opacities of both lungs with areas of nodularity resolved form the previous study. 4. Atelectasis or infiltrate and possible early round atelectasis of the right lower lobe. CODE CRITICAL
REPORT."

Record review revealed the patient was discharged from the DED on 01/04/2016 at 1853 with instructions to follow-up with Physician J in 2 days and a prescription for Coumadin.

Record review revealed no available documentation of a consultation with the pulmonologist (Physician J).

Review of Hospital A's DED Speciality On-Call physician's list revealed pulmonology was available on-call on 01/04/2016 during Patient #4's DED visit.

Review on 05/19/2016 of a "Patient Encounters" form for Hospital A, revealed Patient #4 was directly admitted to Hospital A on 01/07/2016 (3 days following presentation to the DED on 01/04/2016) and was discharged on [DATE]. Review revealed the reason for admission was "SOB" (Shortness of Breath).

Hospital A, closed inpatient medical record review on 05/18/2016 for Patient #4 revealed an admission date of [DATE] at 1120. Review of History and Physical (H&P) documentation by Physician D at 1329 revealed, "Chief Complaints: Directly admitted by (Physician J) for treatment of PE (pulmonary embolism) and further workup will [sic] pleural effusion and epigastric pain. History of Present Illness: ...history of exposure to asbestos and a recent diagnosis of [DIAGNOSES REDACTED]....His pulmonologist wants him to have another imaging guided thoracentesis. The patient's only complaints are cough and epigastric pain....he denies hemoptysis (blood tinged sputum)....His pulmonologist wants to [sic] him to be seen by a gastroenterologist....3 days ago he was in the ED and was diagnosed with [DIAGNOSES REDACTED]. His BNP has increased from 3707 months ago to almost 6000 currently. Review of Systems: Pertinent positives and negatives detailed in history of present illness. Remaining 12 system review is unremarkable. Past Medical History Diagnosis: HTN (hypertension), Lung involvement in other diseases classified elsewhere Lung failure, Pneumothroax, Lung edema. Physical Exam: CV (cardiovascular) - (+) S1S2, no murmurs or gallop....No JVD (jugular vein distention). Resp - Symmetrical and adequate chest expansion. Right lower lobe decreased air entry and coarse crackles ....GI - (+) BS (bowel sounds), soft, mild to moderate epigastric tenderness with some guarding but no rebound. ...Skin - No. ...peripheral edema. Neuro - alert, aware, oriented to person/place/time ...Psych - Appropriate affect....Normal cognition and intellect....Recent Labs: 01/04/16 1725 Creatinine 1.44; BNP 5982..."

Review of the Plan of Care (POC) initiated by (Physician D) revealed the plan was developed and implemented on 01/07/2016 at 1329. Review revealed "Pulmonary embolism, Pleural effusion, bilateral, and CHF (congestive heart failure). Principal Problem: Pulmonary embolism. started [sic] on heparin drip. (Physician J) doesn't want us to transition him to oral anticoagulation until GI (gastroenterology) sees him. Pleural effusion, bilateral (both). Case discussed
VIOLATION: GOVERNING BODY Tag No: A0043
Based on policy and procedure reviews, medical record reviews, specialty physicians on-call list reviews, physician and staff interviews, the hospital's Governing Body failed to provide oversight and have effective systems in place to ensure the hospital met the emergency needs of patients.

The findings include:

1. The hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice for 2 of 25 patients who presented to the hospital's dedicated emergency department for evaluation and treatment of an emergency medical condition (#13 and #4).

~ cross refer to 482.55 Emergency Services - Condition: Tag A1100.


2. The hospital failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program for monitoring of Emergency Medical Treatment and Labor Act ("EMTALA") requirements within the hospital's dedicated emergency department.

~Cross refer to 482.21 QAPI - Condition: Tag A0263.
VIOLATION: QAPI Tag No: A0263
Based on hospital policy and procedure reviews, medical record reviews, speciality physicians on-call list reviews, physician and staff interviews, the hospital failed to maintain an effective, ongoing, hospital-wide, data-driven quality assessment and performance improvement (QAPI) program for monitoring of Emergency Medical Treatment and Labor Act ("EMTALA") requirements within the hospital's dedicated emergency department.

Findings included:

The hospital failed to meet the emergency needs of patients in accordance with acceptable standards of practice for 2 of 25 patients who presented to the hospital's dedicated emergency department for evaluation and treatment of an emergency medical condition (#13 and #4).

~ cross refer to 482.55 - Emergency Services - Condition Tag A1100.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on hospital policy and procedure reviews, medical record reviews, physician and staff interviews, the hospital's Registered Nurse(s) failed to supervise and evaluate the nursing care of patients by failing to ensure assessment and/or re-assessment of vital signs and/or physical condition and/or pain and/or response to medications and/or following STAT physician's orders for 15 of 25 Emergency Department (ED) patient records sampled (#20, #24, #9, #23, #8, #17, #15, #16, #22, #7, #5, #3, #21, #14, and #12); 2 of 2 Women's Unit (WU) patient records sampled (#1 and #2); and 1 of 3 Behavioral Health Unit (BHU) patient records sampled (#33).

Findings included:

Review on 05/18/2016 of Hospital policy, NHw-PC-PE-021, "Assessment/Re-assessment Dimensions" last revised/reviewed: October 13, 2015, revealed "I. SCOPE/PURPOSE: Patients are assessed to determine their past/current physical function and psychosocial status to identify the appropriate care, treatment and services needed. Patients are re-assessed to evaluate changes in their condition and response(s) to the care, treatment and services rendered... II. POLICY ...D. Patients will receive a full/complete assessment by an RN: 1. On admission 2. At least daily and as warranted by the patient's clinical condition... 3. When the patient is transferred from one level of care to another level of care E. Patients will receive a focused re-assessment: 1. At least every shift and as warranted by the patient's clinical condition 2. At regular intervals per service specific standards (see addendums) 3. When there is a change in primary care giver 4. To determine a patient's response to a care intervention ...VI. DOCUMENTATION: All assessments are documented in the patient's medical record. VII. DEFINITIONS: Admission Assessment: Assessment completed by the RN....includes but is not limited to the following components: ...Full/complete assessment ...vital signs, height, weight ...Focused Re-assessment: Any assessment completed after a full/complete assessment. It must include pain assessment as well as assessment of targeted body systems that are pertinent and relevant to the admitting diagnosis, those systems that were abnormal with the full/complete assessment, and those systems at high risk for developing complications/problems. ...Vital Signs: Comprise of temperature [T], pulse [P], respirations [R], and blood pressure [BP]. Vital signs are obtained on admission, as ordered by the physician, and/or as indicated by the patient's condition. ...Pediatric Vital Signs....Patients < (less than) 3 years old: Comprises of temperature [T], pulse [P], respiration [R], and blood pressure [BP] on admission and then comprises of temperature....pulse....respiration....or as ordered by physician. Addendum A Inpatient Units - Nursing ...Women's and Children's Services Services ...Service Labor & Delivery Initiation of Admission Assessment On Arrival to unit Full/Complete Assessments Change in caregiver and/or every shift Fetal Heart Rate/uterine activity per....guidelines Focused Re-Assessments Focused reassessments as patient condition warrants ...Addendum B Interdisciplinary Clinical Services Service: Emergency Department (ED) Adult and Pediatric) Scope and Timeframe of Initial Assessment: Patients are triaged in a timely manner as patient condition warrants. Initial assessment on arrival to the Emergency Department Scope and Timeframe between Re-assessments: Focused reassessments, including vital signs, every 4 hours and within 1 hour of discharge..."

Review on 05/18/2016 of hospital policy, "Vital Signs," last revised/reviewed July 2014 revealed, "I. SCOPE/PURPOSE Vital Signs (VS) are obtained to evaluate the function of cardinal physiological systems and to provide information critical to evaluating homeostatic balance and response to treatment. II. POLICY A. Patients will have vital signs, including temperature, pulse, respiration and blood pressure evaluated on admission, per unit standard (See Table 2), as ordered by physician and/or indicated by patient's condition... TABLE 2. UNIT SPECIFIC VITAL SIGNS SCHEDULE... Unit Women's Unit STANDARD MINIMAL FREQUENCY (ROUTINE VITAL SIGNS) See physician's orders ...Unit Emergency Department STANDARD MINIMAL FREQUENCY....Critically ill patients will have BP, P, R hourly and more frequently based on patient's condition. Adult Level 1 or 2: BP, P, R every 2 hours and PRN based on patient's condition. Pediatric Level 2: P, R, O2 sat (BP if age appropriate) hourly or more frequently, as patient condition warrants. Adult Level 3, 4, or 5: T, P, R, BP - every 4 hours & PRN Pediatric Level 3, 4, or 5: every 2 hours: T, P, R (B if [greater than or equal to] 3). Adult and pediatric patients within one hour of transfer (for patients being admitted into the acute care setting), parameters indicated above for levels 3, 4, 5. ED Pediatric Patients: T, P, R and weight completed initially at triage. BP in all children [greater than or equal to] 3 years of age, with appropriate sized cuff. Note: Patients receiving analgesic medication have P, R & BP checked within 60 minutes after drug administration."

Review on 05/18/2016 of hospital policy, NH-MM-502, "Medication Administration" last revised/reviewed April 15, 2016 revealed, "I. SCOPE/PURPOSE ...is to provide direction to qualified personnel on the administration of medication to include....monitoring... N. Monitoring 1. Monitor the patient's response to medication according to the clinical needs of the patient.. For example, see Pain Assessment and Management - NH-PC-PE-502 a. The patient should be monitored closely monitored following first dose(s) of a medication new to the patient. b. Evaluate the efficacy of the medication..."

Review on 05/18/2016 of hospital policy, NH-PC-PE-502, "Pain Assess and Management", last revised/reviewed July 24, 2013 revealed, "I. SCOPE / PURPOSE....guidelines that facilitate safety and best practice in pain management. II. POLICY The patient has a right to an appropriate assessment of pain at point into the organization and on-going reassessment as appropriate... V. PROCEDURE... a. Pain Evaluation When the patient presents to the organization an evaluation of the presence of pain is completed... 1. Pain Assessment. If the patient presents with pain during the course of treatment a comprehensive/initial assessment is completed.... b. Character of the pain 1) Intensity, description, location and impact on daily living... B. Pain Re-assessments 1. Re-assessments evaluate for any new onset of pain, a focused assessment of current pain... a. Re-assessments occur twice within a calendar day (generally every 12 hours)... b. ...2) A focused pain assessment should at a minimum include location, description, intensity ...VI. DOCUMENTATION The following will be documented in the medical record: -Initial assessment and ongoing pain reassessment -Interventions -Response to interventions..."

Review on 05/19/2016 of hospital policy, NHw-PC-CD-101, "Computerized Provider Order Management (CPOM) Dimensions" last reviewed/revised: November 25, 2014 revealed, "I. SCOPE / PURPOSE Assure that provider orders are entered, processed and documented correctly and completely... II. POLICY....Provider orders shall be....Executed promptly and within the timeframe specified within the order. ...D. Executing Provider Orders 1. Established timeframes recognized include: STAT initiated immediately/ as soon as possible..."
1. Closed ED medical record review on 05/18/2016 for Patient #20 revealed a 7 month old male who (MDS) dated [DATE] at 1742 with a complaint of "skin yellow." Review revealed vital signs (Temperature [T], Heart Rate [HR], Respirations [R], Blood pressure [BP]) were assessed on admission at 1750 as HR 142 and SpO2 (oxygen saturation) 68%. Review revealed vital signs were reassessed at: 1805: HR 145 and SpO2 98% on Non-rebreather; 1807: T 97.3 F (rectal) [T was obtained 17 minutes after admission]; 1819: HR 147 and SpO2 100% on Non-rebreather; 1825: HR 144 and SpO2 100% on Non-rebreather; 1829: HR 143 and Respirations (R obtained 39 minutes after admission); 1833: HR 146 and SpO2 100% on Non-rebreather; 1838: HR 139 and SpO2 100% on Non-rebreather; 1853: T 97.3 F, HR 139, and R 50; 1903: HR 138 and SpO2 100% on Non-rebreather; 1905: HR 137, R 80, and SpO2 100% on Non-rebreather; 1912: HR 136, R 80, and SpO2 100% on Non-rebreather; and 1914: HR 138 and SpO2 100% on Non-rebreather. Review revealed the patient was transferred to another facility at 2022. Review failed to reveal assessments of the patient's respirations or blood pressure upon admission to the ED. Further review revealed no available documentation the patient's vital signs were reassessed within 1 hour (1922-2022) of transfer (discharge) from the ED per hospital policy.
Interview on 05/18/2016 at 1515 with ED Nursing Manager #1 revealed the expectation is for the nursing staff to obtain a "full set" of vital signs on all adult and pediatric patients. Interview revealed a full set of vital signs included BP, heart rate, respiratory rate, temperature and SpO2.
Follow-up interview on 05/19/2016 at 1621 with ED Nursing Manager #1 revealed staff follow the triage policy regarding assessment and re-assessment. Interview revealed vital signs should be obtained upon upon triage and admission to the ED. Interview revealed re-assessment is based on the patient's triage acuity level. Interview revealed staff have not been following the "Assessment/re-assessment Policy" which requires the patient and vital signs to be reassessed within 1 hour of discharge. Interview revealed the Assessment/re-assessment policy is "more strict." Interview revealed she was unaware of the requirement for patients and vital signs to be reassessed within 1 hour of discharge. Interview confirmed the medical record review findings.
2. Closed ED medical record review on 05/18/2016 for Patient #24 revealed a [AGE] year old female, (MDS) dated [DATE] at 1946, with complaint of fall from trampoline. Review revealed vital signs (Temperature [T], Heart Rate [HR], Respirations [R], Blood Pressure [BP]) were assessed on admission at 1954 as T 98.7 F, HR 60, R 16, BP 124/74, and SpO2 98%. Review revealed Patient #24 was discharged from the ED on 04/21/2016 2204 (2 hours and 10 minutes later). Further review revealed no available documentation the patient's vital signs were reassessed within 1 hour (2104-2204) of discharge from the ED per hospital policy.

Interview on 05/18/2016 at 1515 with ED Nursing Manager #1 revealed the expectation is for the nursing staff to obtain a "full set" of vital signs on all adult and pediatric patients. Interview revealed a full set of vital signs included BP, heart rate, respiratory rate, temperature and SpO2.

Interview on 05/19/2016 at 1621 with ED Nursing Manager #1 revealed staff follow the triage policy regarding assessment and re-assessment. Interview revealed vital signs should be obtained upon upon triage and admission to the ED. Interview revealed re-assessment is based on the patient's triage acuity level. Interview revealed staff have not been following the "Assessment/re-assessment Policy" which requires the patient and vital signs to be reassessed within 1 hour of discharge. Interview revealed the Assessment/re-assessment policy is "more strict." Interview revealed she was unaware of the requirement for patients and vital signs to be reassessed within 1 hour of discharge. Interview confirmed the medical record review findings.




3. Closed ED record review on 05/18/2016 for Patient #9 revealed an [AGE] year old female who presented via ambulance to the ED on 04/19/2016 at 1831 with "Chief Complaint Altered Mental Status. Fall 2 days ago, increased altered mental status, seen at PCP (primary care provider) today and xray completed with unknown results, + (positive) pink eye, fever now of 102." Review revealed vital signs (Temperature [T], Heart Rate [HR], Respirations [R], Blood Pressure [BP]) were assessed on admission at 1837 as T 103.1 F (oral), BP 137/66, HR 91, R 20, SpO2 96% on 6L (liters) O2 via nasal cannula. Pain was assessed as 0-denies pain. Review revealed the patient was admitted (discharged from ED) to the intensive care unit (ICU) on 04/20/2016 at 0503. Record review revealed no available documentation of vital signs re-assessment within 1 hour (0403-0503) of transport to the ICU.

Interview on 05/18/2016 at 1515 with ED Nursing Manager #1 revealed the expectation is for the nursing staff to obtain a "full set" of vital signs on all adult and pediatric patients. Interview revealed a full set of vital signs included BP, heart rate, respiratory rate, temperature and SpO2.

Interview on 05/19/2016 at 1621 with ED Nursing Manager #1 revealed staff follow the triage policy regarding assessment and re-assessment. Interview revealed vital signs should be obtained upon upon triage and admission to the ED. Interview revealed re-assessment is based on the patient's triage acuity level. Interview revealed staff have not been following the "Assessment/re-assessment Policy" which requires the patient and vital signs to be reassessed within 1 hour of discharge. Interview revealed the Assessment/re-assessment policy is "more strict." Interview revealed she was unaware of the requirement for patients and vital signs to be reassessed within 1 hour of discharge. Interview confirmed the medical record review findings.


4. Closed ED record review on 05/18/2016 for Patient #23 revealed a [AGE] year old male presented via private transportation to the ED on 03/23/2016 at 1009 with complaint of flank (side) pain. Review revealed at 1037 the patient was triaged by a Registered Nurse (RN). Review revealed vital signs were assessed as Temperature (T) 98.1 degrees Fahrenheit; Heart Rate (HR) 95; Respirations (R) 16; Blood Pressure (BP) 123/75; Oxygen Saturation (SpO2) 99% on room air; and pain was assessed as 4/10 (0 pain free, 10 worst pain). Review revealed the patient was discharged and departed the ED at 1410. Record review failed to reveal any available documentation of vital signs re-assessment within 1 hour (1310-1410) of ED discharge per hospital policy.

Interview on 05/18/2016 at 1515 with ED Nursing Manager #1 revealed the expectation is for the nursing staff to obtain a "full set" of vital signs on all adult and pediatric patients. Interview revealed a full set of vital signs included BP, heart rate, respiratory rate, temperature and SpO2.

Interview on 05/19/2016 at 1621 with ED Nursing Manager #1 revealed staff follow the triage policy regarding assessment and re-assessment. Interview revealed vital signs should be obtained upon upon triage and admission to the ED. Interview revealed re-assessment is based on the patient's triage acuity level. Interview revealed staff have not been following the "Assessment/re-assessment Policy" which requires the patient and vital signs to be reassessed within 1 hour of discharge. Interview revealed the Assessment/re-assessment policy is "more strict." Interview revealed she was unaware of the requirement for patients and vital signs to be reassessed within 1 hour of discharge. Interview confirmed the medical record review findings.

5. Closed ED record review on 05/18/2016 for Patient #8 revealed a [AGE] year old male presented via private transportation to the ED on 03/23/2016 at 1218. Review revealed at 1235 the patient was triaged by a Registered Nurse (RN). Review revealed initial vital signs were assessed as Blood Pressure (BP) 122/73, Heart Rate (HR) 64, Respirations (R) 16, Oxygen Saturation (SPO2) 99% on room air (RA), and pain was assessed as 8/10 (0 pain free, 10 worst pain). Record review revealed the patient was transferred via EMS ambulance to Hospital B and departed the ED at 1452. Record review failed to reveal any available documentation of vital signs re-assessment within 1 hour (1352-1452) prior to transfer (discharge) per hospital policy.

Interview on 05/18/2016 at 1515 with ED Nursing Manager #1 revealed the expectation is for the nursing staff to obtain a "full set" of vital signs on all adult and pediatric patients. Interview revealed a full set of vital signs included BP, heart rate, respiratory rate, temperature and SpO2.

Interview on 05/19/2016 at 1621 with ED Nursing Manager #1 revealed staff follow the triage policy regarding assessment and re-assessment. Interview revealed vital signs should be obtained upon upon triage and admission to the ED. Interview revealed re-assessment is based on the patient's triage acuity level. Interview revealed staff have not been following the "Assessment/re-assessment Policy" which requires the patient and vital signs to be reassessed within 1 hour of discharge. Interview revealed the Assessment/re-assessment policy is "more strict." Interview revealed she was unaware of the requirement for patients and vital signs to be reassessed within 1 hour of discharge. Interview confirmed the medical record review findings.




6. Closed ED record review on 05/18/2016 for Patient #17 revealed a [AGE] year old female who (MDS) dated [DATE] at 1513 for complaint of dyspnea (shortness of breath). Review revealed vital signs (Temperature [T], Heart Rate [HR], Respirations [R], Blood Pressure [BP]) were assessed on admission at 1514 as BP 86/58, HR 100, R 40 and SpO2 78% with 15L (liters) oxygen. Review revealed vital signs were re-assessed at:
1553: BP 90/47, HR 57, and R 26;
1636: BP 119/100, HR 110, R 22 and SpO2 100% on simple mask;
1726: BP 92/60, HR 93, R 20 SpO2 99% on nasal cannula, and T 98.2 F (T obtained 2 hours and 12 minutes after admission to ED);
2003: BP 107/46, HR 111, R 26, SpO2 92% on nasal cannula; and
2019: SpO2 100% on nasal cannula.
Review revealed the patient was transferred from ED to the intensive care unit (ICU) at 2348. Review revealed no available documentation the patient's temperature was assessed upon admission to the ED and vital signs were reassessed within 1 hour (2248-2348) of transport (discharge from ED) to the ICU.

Interview on 05/18/2016 at 1515 with ED Nursing Manager #1 revealed the expectation is for the nursing staff to obtain a "full set" of vital signs on all adult and pediatric patients. Interview revealed a full set of vital signs included BP, heart rate, respiratory rate, temperature and SpO2.

Interview on 05/19/2016 at 1621 with ED Nursing Manager #1 revealed staff follow the triage policy regarding assessment and re-assessment. Interview revealed vital signs should be obtained upon upon triage and admission to the ED. Interview revealed re-assessment is based on the patient's triage acuity level. Interview revealed staff have not been following the "Assessment/re-assessment Policy" which requires the patient and vital signs to be reassessed within 1 hour of discharge. Interview revealed the Assessment/re-assessment policy is "more strict." Interview revealed she was unaware of the requirement for patients and vital signs to be reassessed within 1 hour of discharge. Interview confirmed the medical record review findings.

7. Closed ED record review on 05/18/2016 for Patient #15 revealed a [AGE] year old male presented via private transportation to the ED on 02/29/2016 at 1404 with complaint of "shob (shortness of breath), back pain. Review revealed at 1407 the patient was triaged by a Registered Nurse (RN). Review revealed vital signs were assessed upon admission as Temperature (T) 97.4 F; Heart Rate (HR) 77; Respirations (R) 18; Blood Pressure (BP) 93/69; Oxygen Saturation (SpO2) 96% on room air and pain was assessed as 8/10 (0 pain free, 10 worst pain). Review revealed, "Vital signs stable" at 1514 with no documentation of vital signs results. Review revealed the patient was discharged and departed the ED at 1815. Record review failed to reveal any available documentation vital signs re-assessment within 1 hour (1715-1815) prior to discharge from the ED.

Interview on 05/19/2106 at 0850 with RN #10 revealed she was the nurse assigned to the care of Patient #15 on 02/29/2016. Interview revealed RN #10 documented "Vital signs stable" in the medical record at 1514. Interview revealed no available documentation of vital signs at 1514. "They're not there but it says vital signs stable so I'm most sure they were taken." Interview revealed vital signs "typically cross over from Data Validate from the cardiac monitor. Apparently, the vital signs didn't cross over for some reason." Interview revealed RN #10 discharged the patient at 1816. Interview revealed no available documentation of vital signs assessment within 1 hour of ED discharge at 1816 per hospital policy. Interview confirmed medical record review findings.

Interview on 05/18/2016 at 1515 with ED Nursing Manager #1 revealed the expectation is for the nursing staff to obtain a "full set" of vital signs on all adult and pediatric patients. Interview revealed a full set of vital signs included BP, heart rate, respiratory rate, temperature and SpO2.

Interview on 05/19/2016 at 1621 with ED Nursing Manager #1 revealed staff follow the triage policy regarding assessment and re-assessment. Interview revealed vital signs should be obtained upon upon triage and admission to the ED. Interview revealed re-assessment is based on the patient's triage acuity level. Interview revealed staff have not been following the "Assessment/re-assessment Policy" which requires the patient and vital signs to be reassessed within 1 hour of discharge. Interview revealed the Assessment/re-assessment policy is "more strict." Interview revealed she was unaware of the requirement for patients and vital signs to be reassessed within 1 hour of discharge. Interview confirmed the medical record review findings.

8. Closed ED record review on 05/18/2016 for Patient #16 revealed a [AGE] year old male, who (MDS) dated [DATE] at 1059, with a complaint of shortness of breath, nausea, and chest pain. Review revealed vital signs were assessed and re-assessed as follows:
1129: T 101.1 F (febrile), HR 126, R 20, BP 170/88, and SpO2 93%;
1258: HR 121, R 22, BP 130/64, and SpO2 93%;
1410: HR 123, R 20, BP 128/75, and SpO2 96%; and
1510: HR 123, R 22, BP 130/77, and SpO2 96%.
Review revealed Patient #16 was discharged from the ED on 02/29/2016 1534. Review failed to reveal any available documentation of temperature re-assessment during Patient #16's ED visit on 02/29/2016.

Interview on 05/18/2016 at 1515 with ED Nursing Manager #1 revealed the expectation is for the nursing staff to obtain a "full set" of vital signs on all adult and pediatric patients. Interview revealed a full set of vital signs included BP, heart rate, respiratory rate, temperature and SpO2.

Interview on 05/19/2016 at 1621 with ED Nursing Manager #1 revealed staff follow the triage policy regarding assessment and re-assessment. Interview revealed vital signs should be obtained upon upon triage and admission to the ED. Interview revealed re-assessment is based on the patient's triage acuity level. Interview revealed staff have not been following the "Assessment/re-assessment Policy" which requires the patient and vital signs to be reassessed within 1 hour of discharge. Interview revealed the Assessment/re-assessment policy is "more strict." Interview revealed she was unaware of the requirement for patients and vital signs to be reassessed within 1 hour of discharge. Further interview revealed Patient #16's temperature should have been re-assessed during the ED visit on 02/29/2016. Interview confirmed the medical record review findings.

9. Closed ED record review on 05/18/2016 for Patient #22 revealed a [AGE] year old female who (MDS) dated [DATE] at 1352 for a complaint of "rib pain." Review revealed vital signs upon admission at 1401 were assessed as T 97.9 F, HR 102, R 16, BP 129/86 and SpO2 96%. Review revealed the patient was discharged at 1610. Review revealed no available documentation vital signs were re-assessed within 1 hour (1510-1610) of discharge from the ED per hospital policy.

Interview on 05/18/2016 at 1515 with ED Nursing Manager #1 revealed the expectation is for the nursing staff to obtain a "full set" of vital signs on all adult and pediatric patients. Interview revealed a full set of vital signs included BP, heart rate, respiratory rate, temperature and SpO2.

Interview on 05/19/2016 at 1621 with ED Nursing Manager #1 revealed staff follow the triage policy regarding assessment and re-assessment. Interview revealed vital signs should be obtained upon upon triage and admission to the ED. Interview revealed re-assessment is based on the patient's triage acuity level. Interview revealed staff have not been following the "Assessment/re-assessment Policy" which requires the patient and vital signs to be reassessed within 1 hour of discharge. Interview revealed the Assessment/re-assessment policy is "more strict." Interview revealed she was unaware of the requirement for patients and vital signs to be reassessed within 1 hour of discharge. Interview confirmed the medical record review findings.




10. Closed ED record review on 05/18/2016 for Patient #7 revealed a [AGE] year old male presented via EMS ambulance to the ED on 02/24/2016 at 0920 with an arrival complaint of "fall, SVT (supra[DIAGNOSES REDACTED])." Review revealed at 0921 the patient was triaged by a Registered Nurse (RN). Review revealed at 0924 initial vital signs were assessed as Heart Rate (HR) 175, Respirations (R) 20 and pain was assessed as "Unable to Assess." Review revealed at 0926 Oxygen Saturation (SPO2) was assessed as 79% on nasal cannula. Review revealed at 0950 an initial BP was assessed as 123/85 (26 minutes after initial vital signs were obtained), and the HR, R, and SPO2 was reassessed as HR 135, R 20, SPO2 87% on non-rebreather at 15L/min. Review revealed at 1116 BP was reassessed as 100/60. Review at 1426 revealed "Code Start" and CPR (cardiopulmonary resuscitation) was initiated. Review revealed at 1442 "Code End" and the patient had expired. Record review failed to reveal any available documentation of a BP being assessed at the time of admission and of a temperature being assessed and/or reassessed prior to the patient's death.

Interview on 05/18/2016 at 1515 with ED Nursing Manager #1 revealed the expectation is for the nursing staff to obtain a "full set" of vital signs on all adult and pediatric patients. Interview revealed a full set of vital signs included BP, heart rate, respiratory rate, temperature and SpO2.

Interview on 05/19/2016 at 1621 with ED Nursing Manager #1 revealed staff follow the triage policy regarding assessment and re-assessment. Interview revealed vital signs should be obtained upon upon triage and admission to the ED. Interview revealed re-assessment is based on the patient's triage acuity level. Interview revealed staff have not been following the "Assessment/re-assessment Policy" which requires the patient and vital signs to be reassessed within 1 hour of discharge. Interview revealed the Assessment/re-assessment policy is "more strict." Interview revealed she was unaware of the requirement for patients and vital signs to be reassessed within 1 hour of discharge. Interview confirmed the medical record review findings.

11. Closed ED record review on 05/18/2016 for Patient #5 revealed a [AGE] year old female who (MDS) dated [DATE] at 0646 for complaints of Seizure. Review revealed vital signs (Temperature [T], Heart Rate [HR], Respirations [R], Blood Pressure [BP]) were assessed upon admission at 0648 as HR 126, R 38, BP 157/130, SpO2 92% on room air. Review revealed triage was completed at 0701 and the patient was assigned an acuity level of 2 (1 most severe, 5 least severe).

Review revealed vital signs were reassessed at:
0706: BP 243/161, R 58, and HR 117;
0708: BP 236/151, R 32, HR 111, and SpO2 99%;
0713: BP 230/135, R 28, HR 106, and SpO2 100%;
0718: BP 236/136, R 30, HR 110, and SpO2 100%;
0800: "unable to obtain BP";
0815: BP 270/160 Manual;
0901: BP 250/140 confirmed by 2 RNs; and
1000: BP 235/150
Record review revealed the patient was transferred from the ED to Hospital C at 1120. Review revealed no available documentation of a triage nursing assessment or of ongoing nursing re-assessment of the patient's condition while in the ED by a RN. Review revealed no available documentation a temperature was assessed or of vital signs re-assessment within 1 hour (1020-1120) of departure from the ED to Hospital C on 02/01/2016.

Interview on 05/20/16 at 0845 with RN #10 revealed she was primary nurse for Patient #5 on 02/01/2016. Interview revealed there was no documentation of nursing assessment/ re-assessments in the medical record due to she (RN #10) was focused on blood pressure reading and giving medications.

Interview on 05/18/2016 at 1515 with ED Nursing Manager #1 revealed the expectation is for the nursing staff to obtain a "full set" of vital signs on all adult and pediatric patients. Interview revealed a full set of vital signs included BP, heart rate, respiratory rate, temperature and SpO2.

Interview on 05/19/2016 at 1621 with ED Nursing Manager #1 revealed staff follow the triage policy regarding assessment and re-assessment. Interview revealed vital signs should be obtained upon upon triage and admission to the ED. Interview revealed re-assessment is based on the patient's triage acuity level. Interview revealed staff have not been following the "Assessment/re-assessment Policy" which requires the patient and vital signs to be reassessed within 1 hour of discharge. Interview revealed the Assessment/re-assessment policy is "more strict." Interview revealed she was unaware of the requirement for patients and vital signs to be reassessed within 1 hour of discharge. Interview confirmed the medical record review findings.

12. Closed ED record review on 05/18/2016 for Patient #3, revealed an [AGE] year old male presented via ambulance to the ED on 01/24/2016 at 0806 for complaints of "difficulty breathing and nausea for 3 days..." Review revealed triage was completed at 0820 by a RN. Review revealed vital signs were assessed at 0821 as HR 101 and T 98 F (no documented BP or Temperature upon admission to ED). Review revealed the patient was transferred to Hospital C at 1525. Review revealed vital signs were reassessed at: 0849 - BP 101/54 (obtained 43 minutes after arrival to ED); 0858 - BP 96/46, HR 90, R 26, T 98 F (obtained 52 minutes after arrival to ED), and SpO2 99% (2L via Nasal Cannula); 0908 - BP 91/60, HR 96, R 29, and SpO2 98%; 09
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on Medical Staff Rules and Regulations review, medical record reviews, and Physician interview, the hospital's Medical Staff provider(s) failed to ensure patient medical record entries were completed by the person responsible for providing a service, consistent with hospital polices and procedures in 1 of 2 Women's Unit medical records sampled (#2).

Findings included:

Review on 05/18/2016 of "(Hospital A) Medical Staff Rules & Regulations", Revision: March 2015, revealed, "...Article 2 Medical Records ...2.2 Contents of the Medical Record 2.2.1 The attending member of the Medical Staff shall be responsible for the preparation of a complete and legible medical record for each patient. It shall contain sufficient information to justify the diagnosis, verify the treatment and document the course of treatment and results accurately. The following information shall be included: ...2.2.1.4 Reports of relevant physical examinations ...6.1.4 In the Labor and Delivery Departments 6.1.4.1 Components of the medical screening exam include: 6.1.4.1.1 History and physical examination..."

Review on 05/18/2016 of the closed L&D medical record for Patient #2, revealed a [AGE] year old female who presented to L&D on 04/23/2016 at 1805, with a chief complaint of "Contractions." Review of a Nursing Note written on 04/23/2016 at 1805 by Registered Nurse (RN) #12, revealed, "Pt (Patient) to LD (Labor & Delivery) 3 via stretcher from (Named Emergency Medical Services Agency). Pt to bed. EFM (Electronic Fetal Monitor) and TOCO (tocodynamometer - a component of external monitoring in childbirth) applied. Pt states she's been having ctx (contractions) but got worse this am (morning). (Physician O) at bedside. SVE (Sterile Vaginal Examination) 1 cm (centimeter) by (Physician O)..." Review of a Nursing Note written on 04/23/2016 1908 written by RN # 13, revealed, "Dilation: 1.0, VE (Vaginal Exam) Done by: (Physician O)..." Review of a Nursing Note written on 04/23/2016 1913 by RN #14, revealed, "FHR (Fetal Heart Rate) Comments: (Physician O) reviewing strip..." Record review revealed no available documentation of a report of physical examination performed by Physician O.
Physician O was unavailable for interview during survey.
Telephone interview on 05/20/2016 at 1230, with Physician P, an Obstetrics and Gynecology physician practicing within Hospital A revealed current practice is that notes are only entered by physicians if orders are given, or actions are taken for patients, and not for every assessment performed. Interview confirmed the medical record review finding.