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.

ASCENSION ST JOHN MEDICAL CENTER 1923 SOUTH UTICA AVENUE TULSA, OK 74104 May 15, 2015
VIOLATION: EMERGENCY SERVICES PERSONNEL Tag No: A1110
Based on review of hospital documents, surveyor observations and interviews with hospital staff, the hospital failed to ensure the medical staff defined the duties and role of the mid-level practitioners in the ED.

Findings:

~ On 05/14/2015 at 2:00 p.m. Staff I told the surveyors that mid-level practitioners could provide care and discharge patients with the lesser acuities of Level 4 and Level 5 without direct physician supervision. Staff I stated he thought this was written in the medical staff by-laws and rules and regulations.

~ Medical staff rules and regulations did not address the mid-level practitioners role in the ED.

~ Staff H's credential file did not contain evidence the mid-level practitioner could provide treatment of Level 4 and Level 5 patients without direct supervision of the physician.
VIOLATION: PATIENT RIGHTS: PERSONAL PRIVACY Tag No: A0143
Based on surveyor observations, review of documents and interviews with hospital staff, the hospital failed to ensure a patient's privacy and dignity in two of two patients (Patients #14 and 15) observed in the emergency department (ED) treatment hallways.

Findings:

On 05/14/2015 at 10:45 a.m., the surveyors observed two patients in beds in the emergency department (ED) hallways. These patients were still in the hallways when the surveyors left the ED at 11:45 a.m.

Patients #14 and 15 were in complete view of patients, staff and visitors entering the ED halls. Neither patient had privacy screens or curtains to protect their privacy or dignity.

On 05/14/2015 at 10:45 a.m., Staff G told the surveyors that patients in hallway beds could be assessed, treated and discharged from the hallway bed. Staff G told the surveyors that in addition to the nurse assessing the patient, the mid-level practitioner would also examine the patient. She stated medications, including intravenous therapy, could be provided. Staff G also stated that verbal consent is obtained from the patient(s) prior to placing them in a hallway bed.
VIOLATION: PROGRAM SCOPE, PROGRAM DATA Tag No: A0273
Based on surveyors' observations, review of hospital documents, medical records, and meeting minutes and interviews with staff, the hospital failed to ensure the quality assessment and performance improvement (QAPI) program included monitoring, analysis and development of action plans to remediate or at least reduce the increased length of stay in the emergency department (ED).

Findings:

1. On arrival on the morning of 05/14/2015, the surveyors requested the QAPI meeting minutes where ED concerns and problems were addressed. The surveyors were provided with the Quality/Safety Committee meeting minutes for 2015.

2. The surveyors toured and observed patient/staff interaction and care in the ED on 05/14/2015 between 10:45 a.m. and 11:45 a.m. During that time two patient were observed in beds in the hallways. See Tag A-1104 for details.

3. The ED Staff G told surveyors only patients with the lowest acuity - Level 4 and Level 5 - were placed in hallway beds. Review of hospital policies and procedures for the ED showed the hospital did not have a policy and procedure concerning utilization of hallway beds.

~ Grievances reviewed recorded a patient,
Triaged as a Level 3, complained about being placed in a hallway bed on 01/05/2015.

~ The grievance investigation documented that on 01/15/2015, the ED had converted Zone 4 to an intensive care unit holding. At that time, a child was placed in a hallway bed in Zone 4, just outside the room of a patient that was having febrile seizures.

4. On 05/14/2015, Staff A, D, G and I told the surveyors that discussions of ED problems/concerns were reviewed in the ED physicians, ED nursing staff, leadership, and department managers committee meeting minutes. The 2015 committee meeting minutes reported data and problems in ED, but did not document when the reports were processed through the QAPI program.

5. The 2015 QAPI meeting minutes provided on 05/14/2015, did not address ED hallway bedding and increased ED patient boarding and waiting room times or show that the data discussed in Finding #4 were reviewed with plans of action to improve patient care and outcomes.

6. On 05/15/2015 at 2:00 p.m., Staff L told the surveyors that the ED quality indicators were part of the PI (performance improvement) Report. The 2015 reports were reviewed. The only quality project documented specifically for the ED was blood culture contamination.

7. The findings were reviewed with administrative staff at the exit conference on the afternoon of 05/15/2015. No additional data was provided.
VIOLATION: PROGRAM DATA, PROGRAM ACTIVITIES Tag No: A0283
Based on surveyors' observations, review of hospital documents and interviews with staff, the hospital failed to ensure the quality assessment and performance improvement (QAPI) committee set priorities for improvement based on relevant data that identified high-risk, high-volume and problem-prone areas. There was no documentation the QAPI committee prioritized health outcomes, patient safety and quality of care.

Findings:

1. On 05/14/2015 at 10:45 a.m., the surveyors observed two patients in beds in the emergency department (ED) hallways. These patient were still in the hallways when the surveyors left the ED at 11:45 a.m.

~ Staff G told the surveyors on 05/14/2015 at 10:50 a.m. that patients were placed in the hallways when all the ED rooms/beds were full.

~ Staff I told the surveyors on 05/14/2015 at 1:30 p.m. that the hospital averaged about 5000 patients per month through the ED. He told the surveyors that the hospital had decided to place patients with lower level acuity in hallway beds when all the ED rooms/beds were full so they could receive treatment quicker.

~ On 05/14/2015 at 2:25 p.m., when asked about reports on the number of patients that were placed in hallway beds, Staff I stated they were not tracked, but thought it could be obtained.

~ On 05/15/2015 Staff A, D and G told the surveyors that hallway bed information was not tracked and no information could be provided.

The 2015 QAPI meeting minutes did not contain evidence this implementation of hallway bed use was processed through the QAPI program to determine the quality of patient care, patient safety and if personal privacy was provided.


2. Staff G told the surveyors that placing patient in hallway beds could occur because the ED was keeping patients in the ED beds if there were no intensive care unit (ICU) beds available. The patient would be held in the ED until an ICU bed would become available. Staff G stated that at times the ED designated a Zone (area of the ED - there are 5 Zones) as ICU hold.

~ Staff I reported in the emergency medicine department meeting minutes that in January 2015 the patient boarding was around 2500 hours. (The hospital had a written definition of boarding as any patient waiting longer than four (4) hours for a bed assignment.)

~ Staff I stated on 05/14/2015 at 1:30 that the hospital had developed a "Capacity Plan" as an option to decrease the amount of boarding hours. He stated that although the majority of ED boarding was awaiting an ICU bed, the "Capacity Plan" looked at all patient beds to determine if patients could be moved to different units or discharged .

~ Staff A repeated and confirmed the implementation and role of the "Capacity Plan" to the surveyors on 05/14/2015 3:00 p.m.

The 2015 QAPI meeting minutes did not contain evidence the process of boarding in the ED and implementation of the "Capacity Plan" was reviewed and analyzed through the QAPI program to determine if this plan of action was effective, followed standards of care and did not have a negative outcome on meeting the goals of providing care to ED patients.


3. The 2015 QAPI meeting minutes did not contain evidence ED medical records were reviewed for completeness and accuracy of documentation.

4. On 05/15/2015 at 2:00 p.m., Staff L told the surveyors that the ED quality indicators were part of the PI (performance improvement) Report. The 2015 reports were reviewed. The only quality project documented specifically for the ED was blood culture contamination.
VIOLATION: QUALITY ASSESSMENT AND PERFORMANCE IMPROVEMENT Tag No: A0308
Based on surveyor observations, review of hospital documents and interviews with staff, the hospital failed to:

a. require the Quality Assessment and Performance Improvement (QAPI) program to reflect the complexity and scope of hospital services provided;

b. focus QAPI indicators on improving patient heath outcome;

c. provide adequate documentation to demonstrate evidence the QAPI committee reviewed valid and relevant data;

d. ensure the QAPI committee identified opportunities for improvement and recommended changes that would lead to improvement;

e. set specific priorities for performance improvement;

Findings:

1. There was no documentation the QAPI program changed to reflect changes in hospital services.

2. While there were health outcome indicators included in the QAPI program, there was no documentation the QAPI committee reviewed and responded to information identified through patient complaints and grievances investigations about emergency services (ED).

3. There was no documentation in the QAPI committee meeting minutes that showed problems identified in other committees meetings concerning the ED were processed through the QAPI program.

4. There was no documentation the QAPI committee set priorities for improvement based on relevant data that identified high-risk, high-volume and problem-prone areas. There was no documentation the QAPI committee prioritized health outcomes, patient safety and quality of care for patients presenting to the ED.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
Based on review of hospital documents and medical records and interviews with hospital staff, the hospital failed to ensure the registered nurse evaluated patient care interventions and informed the physician of changes in the patient's condition in one of three (Patient #9) patients that admitted to intensive care unit (ICU) status, but were kept in an emergency department (ED) bed/room.

Findings:

Patient #9 was brought to the ED by ambulance staff on 01/07/2015 at 2:53 p.m. , the patient was triaged as a level 1 and transported to ED room 1. The patient was intubated and unresponsive at the time. According to documentation in the medical record, the patient became responsive and was extubated at 5:20 p.m. The patient was admitted the intensive care unit (ICU) to the services of the "Gold team" at 4:19 p.m.

The patient was placed on a BiPAP (bilevel positive airway pressure) machine at 5:28 p.m. Vital signs charted after initiation of the BiPAP on 01/07/2015 recorded the patient's oxygen saturation rate decreased below 90% at 5:50 p.m. (68%), 6:58 p.m. (67%), 8:15 p.m. (89%), 8:45 p.m. (84%) and 9:45 p.m. (80%).

Nursing notes on 01/07/2015 at 7:45 p.m., 8:30 p.m., 8:45 p.m., 9:15 p.m., and 9:30 p.m. documented the patient kept grabbing at the mask and taking the mask off. Interventions documented was replacing the mask and education to patient and family member about the importance of keeping the mask on.

There is no documentation of other interventions tried or considered. The medical record did not contain evidence the physician was informed of the patient's change in condition.

On 05/15/2015 at 2:00 p.m., Staff P told the surveyor she did not find documentation of the nurse informing the physician of the patient not keeping the BiPAP mask in place and the patient's decrease in oxygen saturation level.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
Based on surveyors' observations, review of hospital documents and interviews with staff, the hospital failed to ensure the medical staff:
a. developed, enforced and evaluated policies and procedures to direct patient care processes; and
b. provided data to the hospital quality assessment and performance improvement (QAPI) process for evaluation and possible corrective actions.

Findings:

The surveyor toured the emergency department (ED) and observed care on 05/14/2015 between 10:45 a.m. and 11:45 a.m. The ED was divided into 5 separate areas, called Zones.

1. On arrival in the ED at 10:45 a.m., two patients were observed in beds in the hallways, one patient in Zone 2 and one patient in Zone 5. These patients were still in the hallways when the surveyors left the ED at 11:45.

~ On 05/14/2015 at 10:45 a.m., Staff G told the surveyors that when all rooms were full, they were allowed to put patients in "designated" hall beds. Staff G stated the established capacity for hall beds was seven.

~ On 05/14/2015 at 10:50 a.m., Staff G told the surveyors that she did not think there was a policy on the designated hall beds, but stated they put the lower acuity, Levels 4 and 5, in the hall beds. The patient would not have to be put in a gown. These patients would be seen by the nurse practitioner.

~ Grievance documentation recorded Patient #8 complained of being placed in the ED hall on 01/15/2015. The investigation documented the patient was placed in a "hallbed" . The patient was triaged as a Level 3, (This triage level is a more acute acuity level than the surveyors were told would be placed and treated in the hallway.)

~ The same hospital grievance investigation documented that also on 01/15/2015, the ED had converted Zone 4 to an intensive care unit (ICU) holding. At this time, a child was placed in a hallway bed in Zone 4. The child's bed was located just outside a room where a patient was having febrile seizures.

~ Review of hospital policies and procedures for the ED confirmed the hospital did not have a policy and procedure concerning utilization of hallway beds and the role of the emergency medical personnel prior to hand-off.


2. During the tour on 05/14/2015, Staff D and G told the surveyors that patients were kept in the ED while awaiting beds.

~ On 05/14/2015, Staff G told the surveyors when there were no ICU beds, the patient would be held in the ED until an ICU bed would become available. Staff G stated that at times the ED designated a Zone (area of the ED - there are 5 Zones) as ICU hold. Staff G told the surveyors that ICU staff, nursing and physicians came to the ED and provided care for those patients in ICU hold.

~ The hospital did not have ED policies and procedures concerning the boarding/keeping of patients in the ED when hospital units,including the ICUs, were full that addressed:
a. how long would patients be kept in ED beds before it would be determined the hospital did not have the capacity to provide inpatient care for the patients;
b. what would be the maximum number of patients that would be held in the ED awaiting admission; and
c. who provided the supervision of ICU staff who provided care to patients occupying ED beds to ensure the patients care needs were being met and how would this supervision be documented/shown.


3. The hospital did not have an ED policy and procedure that addressed the role of the mid-level practitioner in providing a medical screening examination, treatments, and discharge of patients.


4. The QAPI meeting minutes did not show ED hallway bedding and increased ED patient boarding and waiting times were reviewed and processed.