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.

MEMORIAL HERMANN BAPTIST ORANGE HOSPITAL 608 STRICKLAND DRIVE ORANGE, TX Aug. 1, 2014
VIOLATION: GOVERNING BODY Tag No: A0043
Based on document review and interview the Governing Body failed to:

A. ensure emergency room services complied with the requirements of 42 CFR ?482.55.

Refer to tag A0092

B. ensure registered nurses supervised and evaluated 2 of 21 patients seeking care in the facility's emergency room .

Refer to tag A0395

C. enforce the medical Staff Rules and Regulations and the policy titled Medical Screening, Consultations, Treatment, and Transfer Policy. 2 0f 21 patients (patient #18 and #21) did not receive timely medical screening.

Refer to tag A
VIOLATION: EMERGENCY SERVICES Tag No: A0092
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview the governing body failed to ensure a timely medical screenings and nursing care in accordance to accepted standards of care to 2 of 21 (patients #18, and 21) patients seeking care in the emergency room . Patient #21 presented to the facility's emergency with symptoms of having a stroke. Patient #21 was placed in the waiting room for 50 minutes and no treatment was provided. Patient #18 presented with a complaint of a headache, pain level of 7 out of 10, anxious and agitated and a blood pressure of 191/118. Patient #18 was placed in the waiting room for 1 hour and 20 minutes and no treatment was provided. Registered nursing staff failed to follow policies and triage patients appropriately according to the standards for assessment and patient classifications.
Review of patient emergency room record dated 12/21/2013 revealed the following:
Patient #21 arrived at the facility's emergency room on [DATE] at 13:37 (1:37 PM) by way of ambulance. The ambulance service document titled, Initial Pre-hospital Care Report revealed;
Chief complaint: numbness to right leg
PMS (Past Medical History): hypertension, TIA (transient ischemic attack), Diabetes
Pulse 79, B/P (blood pressure) 179/70, SpO2 (oxygen saturation) 98%
Response to Treatment/Narrative: Pt. (patient) states rt. (right) hand/shoulder started feeling numb yesterday morning. Last night she noticed her rt. leg was going numb and dragging.

A review of the document titled Emergency Nursing Record; Neuro Deficit Complaints revealed:
Triage Date: 12/21/13 Time: 1340, Acuity 3 (ESI)
Historian: Paramedic
Arrival Mode EMS
Vitals: B/P 165/71, P 78, RR (reparations) 16, Temp 98.6, SpO2 97%
Chief Complaint: Right hand/shoulder/leg started 24 hrs ago. Sudden onset numbness yesterday morning. Walking around per EMS.
Past Medical HX:HTN, diabetes, TIA
Blood Sugar 127
Additional Notes: 1430 (2:30PM)- Told reg. clerk she was leaving.
Depart Date 12/21 Time 1430

A review of the document with the titled heading, Please Fill Out This Form For Each Patient revealed the patient's demographics:
Date 12/21/13
Time 1:30 PM
Name: patient #21 ....
Reason For This Visit: Stroke

A phone interview was conducted with patient #21's sister on 07/24/2014 at approximately 4:00PM. The interview revealed patient #21 was having stroke like symptoms and had called EMS to transport her (patient #21) to the hospital. Patient #21's sister had met the ambulance at the facility. The sister revealed as they removed patient #21 from the ambulance she along with EMS and the patient entered the ER. The EMS personnel gave report to a nurse. The nurse instructed the EMS personnel to put the patient in a wheel chair and place her in the waiting room. The patient #21 was triaged shortly after being placed in the waiting room. Patient #21 was placed back in the waiting room after being triaged. Patient #21's sister revealed she repeatedly told the registration clerk the patient was getting worse. Patient #21's speech was being affected and was slurring words. The clerk's response was the nurses knew the patient was in the waiting room and would get to her as soon as possible. After waiting approximately one hour and 50 minutes in the waiting room with no response from the ER staff after repeated request for help the decision was made to seek medical attention at a different facility. Patient #2 was admitted with a stroke and placed in ICU.

A review of patient emergency room record dated 06/16/2014 revealed patient #18 arrived at the facility's emergency room at 17:11 (5:11 PM). The Presenting complaint: Patient states: Headache, Blood Pressure evaluated...Care prior to arrival: Has taken blood pressure med and 3 clonidine today.
17:22 Acuity: 3-Urgent (ESI)
Triage Assessment: 17:26 General: Appears well nourished, well groomed. General: Behavior is agitated, anxious. Pain: Complains of pain in Head. Pain currently is 7 out of 10 on a pain scale. Pain began about a week ago.
Vital Signs: 17:20 B/P 191/118, Pulse 112, Resp. 18, Temp 98.5.
18:40 .... Pt. not in waiting room when called to take to a room.
18:59 Patient left the ED.

Patient #18's emergency room medical record revealed a wait time of 1 hour and 29 minutes with no evidence of the patient being re-evaluated.

A review of the document titled TRIAGE ASSESSMENT AND PATIENT CLASSIFICATION, PROCESS STANDARDS revealed:
Patient acuity level will be determined using ESI system guidelines. The Triage Nurse(s) is/are assigned by the Clinical Coordinator or Charge Nurse and is subject to change based upon department needs.
PROCEDURE
1. A Registered Nurse will perform the triage assessment and assign the appropriate ESI level
2. Assess each patient's chief complaint and vital signs. This information will be documented on the Emergency Services Record.
3. Patients will be assigned the appropriate triage 1evel
? Category 1 - Emergent
? Category 2 - Semi emergent
? Category 3 - Urgent
? Category 4 - Semi urgent
? Category 5 - Non urgent
4. When appropriate, the Triage Nurse should initiate approved ED protocol order sets.
5. Patients in the waiting area should be reassessed periodically to determine if the triage level has changed.

A review of the document titled SUBJECT STANDARDS OF PRACTICE EMERGENCY DEPARTMENT PRACTICE STANDARDS
POLICY STATEMENT
In addition to the ANA Standards of Care adopted for the Department of Nursing, patients presenting to the Emergency Department have the right to expect certain standards of care
PROCESS
To facilitate the attainment of Outcome Standards,
STANDARD 1: Upon admission to die Emergency. Department, the patient will be triaged and his condition identified and referred to the physician as is appropriate and in as expedient a manner as possible
STANDARD 2: If it is necessary that the patient has to wait for care as a result of emergencies or other priorities, the patient will be kept informed as to the reason for die wait
STANDARD 3: Once admitted , the patient's condition will be monitored closely for any changes in condition and his priority in being seen or treated will be changed according to his changing needs.
A review of blood pressure categories defined by the American Heart Association revealed a systolic pressure higher than 180 or a diastolic pressure higher than 110 is a hypertensive crises.
Hypertensive crises can present as hypertensive urgency or as a hypertensive emergency.
Hypertensive urgency is a situation where the blood pressure is severely elevated [180 or higher for your systolic pressure (top number) or 110 or higher for your diastolic pressure (bottom number)], but there is no associated organ damage. Those experiencing hypertensive urgency may or may not experience one or more of these symptoms:
? Severe headache
? Shortness of breath
? Nosebleeds
? Severe anxiety
Treatment of hypertensive urgency generally requires readjustment and/or additional dosing of oral medications, but most often does not necessitate hospitalization for rapid blood pressure reduction. A blood pressure reading of 180/110 or greater requires immediate evaluation, because early evaluation of organ function and blood pressure elevations at these levels is critical to determine the appropriate management.

A review of the Emergency Severity Index (ESI), A Triage Tool for Emergency Department Care revealed:

Patients who meet ESI level-2 criteria should have their placement rapidly facilitated. ESI does not specify timeframe to physician evaluation, unlike many other triage systems. However, it is understood that level-2 patients should be evaluated as soon as possible.
The following three questions should be answered and are key components of
ESI level-2 criteria:
? Is this a high-risk situation?
? Is the patient experiencing new onset confusion, lethargy, or disorientation?
? Is the patient experiencing severe pain or distress?

1. Is This a High-Risk Situation?
The ability to recognize a high-risk situation is a critical element of the triage decision-making process, regardless of the triage system used. ESI highlights the importance of recognizing high-risk situations and uses the triage nurse ' s expertise and experience to identify patients at high risk.

Neurological
Patients with severe headache associated with mental status changes, high blood pressure, lethargy, fevers, or a rash should be considered high-risk.

2. Is the Patient Experiencing
New Onset Confusion, Lethargy, or Disorientation?
The second question to consider when determining whether a patient meets level-2 criteria is, " Does the patient have new onset confusion, lethargy, or disorientation? "

3. Is the Patient Experiencing
Severe Pain or Distress?
The third and final question to address when determining whether the patient meets level-2 criteria is, " Is the patient experiencing severe pain or distress? "

Is the Patient in Severe Pain or Distress?
The third question the triage nurse needs to answer at decision point B is whether this patient is currently in pain or distress. If the answer is "no," the triage nurse is able to move to the next step in the algorithm. If the answer is "yes," the triage nurse needs to assess the level of pain or distress. This is determined by clinical observation and/or a self- reported pain rating of 7 or higher on a scale of 0 to10. When patients report pain ratings of 7/10 or greater, the triage nurse may triage the patient as ESI level 2, but is not required to assign a level-2 rating.

Once an ESI level-2 patient is identified, the triage nurse needs to ensure that the patient is cared for in a timely manner. Registration can be completed by a family member or at the bedside. ESI level-2 patients need vital signs and a comprehensive nursing assessment but not necessarily at triage. Placement in the treatment area is a priority and should not be delayed to finish obtaining vital signs or asking additional questions.


An interview with staff #3 the ED Director on 7/25/2014 at approximately 11:30AM in the Administrative Conference Room revealed the facility was actively working to reduce the emergency room wait time. Interviewee revealed wait times were being monitored daily and addressed as needed with the staff. The interviewee revealed that LWOT (left without treatment) were usually due to patients not wanting to wait. The interviewee was asked if the LWOT's medical records were being reviewed/audited by the facility. The response was NO.

It was determined that these deficient practices created an Immediate Jeopardy situation, resulting in a likelihood of harm and serious injury to all patients, staff, and visitors.
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the facility failed to provide registered nurse supervision and evaluation of 2 of 21 (patients #18, and 21) patients seeking care in the emergency room .
Patient #21 presented to the facility's emergency with symptoms of having a stroke. Patient #21 was placed in the waiting room for 50 minutes and no treatment was provided.
Patient #18 presented with a complaint of a headache, pain level of 7 out of 10, anxious and agitated and a blood pressure of 191/118. Patient #18 was placed in the waiting room for 1 hour and 20 minutes and no treatment was provided.
Registered nursing staff failed to follow policies and triage patients appropriately according to the standards for assessment and patient classifications.
Review of patient emergency room record dated 12/21/2013 revealed the following:
Patient #21 arrived at the facility's emergency room on [DATE] at 13:37 (1:37 PM) by way of ambulance. The ambulance service's document titled, Initial Pre-hospital Care Report revealed:

Chief complaint: numbness to right leg
PMS (Past Medical History): hypertension, TIA (transient ischemic attack), Diabetes
Pulse 79, B/P (blood pressure) 179/70, SpO2 (oxygen saturation) 98%
Response to Treatment/Narrative: Pt. (patient) states rt. (right) hand/shoulder started feeling numb yesterday morning. Last night she noticed her rt. leg was going numb and dragging.

A review of the document titled Emergency Nursing Record; Neuro Deficit Complaints revealed:

Triage Date: 12/21/13 Time: 1340, Acuity 3 (ESI)
Historian: Paramedic
Arrival Mode EMS
Vitals: B/P 165/71, P 78, RR (reparations) 16, Temp 98.6, SpO2 97%
Chief Complaint: Right hand/shoulder/leg started 24 hrs ago. Sudden onset numbness yesterday morning. Walking around per EMS.
Past Medical HX:HTN, diabetes, TIA
Blood Sugar 127
Additional Notes: 1430 (2:30PM)- Told reg. clerk she was leaving.
Depart Date 12/21 Time 1430

A review of the document with the title, Please Fill Out This Form For Each Patient revealed the patient's demographics:

Date 12/21/13
Time 1:30 PM
Name: patient #21 ....
Reason For This Visit: Stroke

A phone interview was conducted with patient #21's sister on 07/24/2014, at approximately 4:00PM. The interview revealed that patient #21 was having stroke like symptoms and had called EMS to transport her (patient #21) to the hospital. Patient #21's sister had met the ambulance at the facility. The sister revealed that as they removed patient #21 from the ambulance, she, along with EMS and the patient, entered the ER. The EMS personnel gave report to a nurse. The nurse instructed the EMS personnel to put the patient in a wheel chair and place her in the waiting room. The patient #21 was triaged shortly after being placed in the waiting room. Patient #21 was placed back in the waiting room after being triaged. Patient #21's sister revealed she repeatedly told the registration clerk that the patient was getting worse. Patient #21's speech was being affected and was slurring words. The clerk's response was that the nurses knew the patient was in the waiting room and would get to her as soon as possible. After waiting approximately an hour in the waiting room, with no response from the ER staff after repeated request for help, the decision was made to seek medical attention at a different facility. Patient #2 was admitted with a stroke and placed in ICU.


A review of patient emergency room record dated 06/16/2014 revealed that Patient #18 arrived at the facility's emergency room at 17:11 (5:11 PM). The Presenting complaint: Patient states: Headache, Blood Pressure evaluated...Care prior to arrival: Has taken blood pressure med and 3 clonidine today.
17:22 Acuity: 3-Urgent (ESI)
Triage Assessment: 17:26 General: Appears well nourished, well groomed. General: Behavior is agitated, anxious. Pain: Complains of pain in Head. Pain currently is 7 out of 10 on a pain scale. Pain began about a week ago.
Vital Signs: 17:20 B/P 191/118, Pulse 112, Resp. 18, Temp 98.5.
18:40 .... Pt. not in waiting room when called to take to a room.
18:59 Patient left the ED.

Patient #18's emergency room medical record revealed a wait time of 1 hour and 29 minutes with no evidence of the patient being re-evaluated.

A review of the document titled TRIAGE ASSESSMENT AND PATIENT CLASSIFICATION, PROCESS STANDARDS revealed:

Patient acuity level will be determined using ESI system guidelines. The Triage Nurse(s) is/are assigned by the Clinical Coordinator or Charge Nurse and is subject to change based upon department needs.

PROCEDURE

1. A Registered Nurse will perform the triage assessment and assign the appropriate ESI level

2. Assess each patient's chief complaint and vital signs. This information will be documented on the Emergency Services Record.

3. Patients will be assigned the appropriate triage 1evel
? Category 1 - Emergent
? Category 2 - Semi emergent
? Category 3 - Urgent
? Category 4 - Semi urgent
? Category 5 - Non urgent

4. When appropriate, the Triage Nurse should initiate approved ED protocol order sets.

5. Patients in the waiting area should be reassessed periodically to determine if the triage level has changed.

A review of the document titled SUBJECT STANDARDS OF PRACTICE EMERGENCY DEPARTMENT PRACTICE STANDARDS

POLICY STATEMENT

In addition to the ANA Standards of Care adopted for the Department of Nursing, patients presenting to the Emergency Department have the right to expect certain standards of care

PROCESS

To facilitate the attainment of Outcome Standards,

STANDARD 1: Upon admission to die Emergency. Department, the patient will be triaged and his condition identified and referred to the physician as is appropriate and in as expedient a manner as possible

STANDARD 2: If it is necessary that the patient has to wait for care as a result of emergencies or other priorities, the patient will be kept informed as to the reason for die wait

STANDARD 3: Once admitted , the patient's condition will be monitored closely for any changes in condition and his priority in being seen or treated will be changed according to his changing needs.
A review of blood pressure categories defined by the American Heart Association revealed a systolic pressure higher than 180 or a diastolic pressure higher than 110 is a hypertensive crises.
Hypertensive crises can present as hypertensive urgency or as a hypertensive emergency.
Hypertensive urgency is a situation where the blood pressure is severely elevated [180 or higher for your systolic pressure (top number) or 110 or higher for your diastolic pressure (bottom number)], but there is no associated organ damage. Those experiencing hypertensive urgency may or may not experience one or more of these symptoms:
? Severe headache
? Shortness of breath
? Nosebleeds
? Severe anxiety
Treatment of hypertensive urgency generally requires readjustment and/or additional dosing of oral medications, but most often does not necessitate hospitalization for rapid blood pressure reduction. A blood pressure reading of 180/110 or greater requires immediate evaluation, because early evaluation of organ function and blood pressure elevations at these levels is critical to determine the appropriate management.

A review of the Emergency Severity Index (ESI), A Triage Tool for Emergency Department Care revealed:

Patients who meet ESI level-2 criteria should have their placement rapidly facilitated. ESI does not specify timeframe to physician evaluation, unlike many other triage systems. However, it is understood that level-2 patients should be evaluated as soon as possible.
The following three questions should be answered and are key components of
ESI level-2 criteria:
? Is this a high-risk situation?
? Is the patient experiencing new onset confusion, lethargy, or disorientation?
? Is the patient experiencing severe pain or distress?

1. Is This a High-Risk Situation?
The ability to recognize a high-risk situation is a critical element of the triage decision-making process, regardless of the triage system used. ESI highlights the importance of recognizing high-risk situations and uses the triage nurse ' s expertise and experience to identify patients at high risk.

Neurological
Patients with severe headache associated with mental status changes, high blood pressure, lethargy, fevers, or a rash should be considered high-risk.

2. Is the Patient Experiencing
New Onset Confusion, Lethargy, or Disorientation?
The second question to consider when determining whether a patient meets level-2 criteria is, " Does the patient have new onset confusion, lethargy, or disorientation? "

3. Is the Patient Experiencing
Severe Pain or Distress?
The third and final question to address when determining whether the patient meets level-2 criteria is, " Is the patient experiencing severe pain or distress? "

Is the Patient in Severe Pain or Distress?
The third question the triage nurse needs to answer at decision point B is whether this patient is currently in pain or distress. If the answer is "no," the triage nurse is able to move to the next step in the algorithm. If the answer is "yes," the triage nurse needs to assess the level of pain or distress. This is determined by clinical observation and/or a self- reported pain rating of 7 or higher on a scale of 0 to10. When patients report pain ratings of 7/10 or greater, the triage nurse may triage the patient as ESI level 2, but is not required to assign a level-2 rating.

Once an ESI level-2 patient is identified, the triage nurse needs to ensure that the patient is cared for in a timely manner. Registration can be completed by a family member or at the bedside. ESI level-2 patients need vital signs and a comprehensive nursing assessment but not necessarily at triage. Placement in the treatment area is a priority and should not be delayed to finish obtaining vital signs or asking additional questions.


An interview with staff #3 the ED Director on 7/25/2014, at approximately 11:30AM, in the Administrative Conference Room revealed the facility was actively working to reduce the emergency room wait time. Interviewee revealed wait times were being monitored daily and addresses as needed with the staff. The interviewee revealed that LWOT (left without treatment) were usually due to patients not wanting to wait. The interviewee was asked if the LWOT's medical records were being reviewed/audited by the facility. The response was NO.

It was determined that these deficient practices created an Immediate Jeopardy situation, resulting in a likelihood of harm and serious injury to all patients, staff, and visitors.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the facility failed to provide a timely medical assessment and nursing care based on established standard of care to 2 of 21 (patients #18, and 21) patients seeking care in the emergency room .
Patient #21 presented to the facility's emergency with symptoms of having a stroke. Patient #21 was placed in the waiting room for 50 minutes and no treatment was provided.
Patient #18 presented with a complaint of a headache, pain level of 7 out of 10, anxious and agitated and a blood pressure of 191/118. Patient #18 was placed in the waiting room for 1 hour and 20 minutes and no treatment was provided. Registered nursing staff failed to follow policies and triage patients appropriately according to the standards for assessment and patient classifications.
Review of patient emergency room record dated 12/21/2013, revealed the following:
Patient #21 arrived at the facility's emergency room on [DATE], at 13:37 (1:37 PM), by way of ambulance. The ambulance service's document titled, Initial Pre-hospital Care Report revealed:

"Chief complaint: numbness to right leg
PMS (Past Medical History): hypertension, TIA (transient ischemic attack), Diabetes
Pulse 79, B/P (blood pressure) 179/70, SpO2 (oxygen saturation) 98%
Response to Treatment/Narrative: Pt. (patient) states rt. (right) hand/shoulder started feeling numb yesterday morning. Last night she noticed her rt. leg was going numb and dragging."

A review of the document titled Emergency Nursing Record; Neuro Deficit Complaints revealed:
"Triage Date: 12/21/13 Time: 1340, Acuity 3 (ESI)
Historian: Paramedic
Arrival Mode EMS
Vitals: B/P 165/71, P 78, RR (reparations) 16, Temp 98.6, SpO2 97%
Chief Complaint: Right hand/shoulder/leg started 24 hrs ago. Sudden onset numbness yesterday morning. Walking around per EMS.
Past Medical HX:HTN, diabetes, TIA
Blood Sugar 127
Additional Notes: 1430 (2:30PM)- Told reg. clerk she was leaving.
Depart Date 12/21 Time 1430"

A review of the document with the titled heading, Please Fill Out This Form For Each Patient revealed the patient's demographics:
"Date 12/21/13
Time 1:30 PM
Name: patient #21 ....
Reason For This Visit: Stroke"

A phone interview was conducted with patient #21's sister on 07/24/2014, at approximately 4:00PM. The interview revealed patient #21 was having stroke like symptoms and had called EMS to transport her (patient #21) to the hospital. Patient #21's sister had met the ambulance at the facility. The sister revealed as they removed patient #21 from the ambulance, she, along with EMS and the patient entered, the ER. The EMS personnel gave report to a nurse. The nurse instructed the EMS personnel to put the patient in a wheel chair and place her in the waiting room. The patient #21 was triaged shortly after being placed in the waiting room. Patient #21 was placed back in the waiting room after being triaged. Patient #21's sister revealed she repeatedly told the registration clerk the patient was getting worse. Patient #21's speech was being affected and was slurring words. The clerk's response was the nurses knew the patient was in the waiting room and would get to her as soon as possible. After waiting approximately an hour in the waiting room ,with no response from the ER staff after repeated request for help, the decision was made to seek medical attention at a different facility. Patient #2 was admitted with a stroke and placed in ICU.

A review of patient emergency room record dated 06/16/2014, revealed patient #18 arrived at the facility's emergency room at 17:11 (5:11 PM). "The Presenting complaint: Patient states: Headache, Blood Pressure evaluated...Care prior to arrival: Has taken blood pressure med and 3 clonidine today.
17:22 Acuity: 3-Urgent (ESI)
Triage Assessment: 17:26 General: Appears well nourished, well groomed. General: Behavior is agitated, anxious. Pain: Complains of pain in Head. Pain currently is 7 out of 10 on a pain scale. Pain began about a week ago.
Vital Signs: 17:20 B/P 191/118, Pulse 112, Resp. 18, Temp 98.5.
18:40 .... Pt. not in waiting room when called to take to a room.
18:59 Patient left the ED."

Patient #18's emergency room medical record revealed a wait time of 1 hour and 29 minutes with no evidence of the patient being re-evaluated.

A review of the document titled "TRIAGE ASSESSMENT AND PATIENT CLASSIFICATION, PROCESS STANDARDS" revealed:

"Patient acuity level will be determined using ESI system guidelines. The Triage Nurse(s) is/are assigned by the Clinical Coordinator or Charge Nurse and is subject to change based upon department needs.

PROCEDURE

1. A Registered Nurse will perform the triage assessment and assign the appropriate ESI level

2. Assess each patient's chief complaint and vital signs. This information will be documented on the Emergency Services Record.

3. Patients will be assigned the appropriate triage 1evel
? Category 1 - Emergent
? Category 2 - Semi emergent
? Category 3 - Urgent
? Category 4 - Semi urgent
? Category 5 - Non urgent

4. When appropriate, the Triage Nurse should initiate approved ED protocol order sets.

5. Patients in the waiting area should be reassessed periodically to determine if the triage level has changed."

A review of the document titled "SUBJECT: STANDARDS OF PRACTICE EMERGENCY DEPARTMENT PRACTICE STANDARDS

POLICY STATEMENT -

"In addition to the ANA Standards of Care adopted for the Department of Nursing, patients presenting to the Emergency Department have the right to expect certain standards of care.

PROCESS

To facilitate the attainment of Outcome Standards,

STANDARD 1: Upon admission to die Emergency. Department, the patient will be triaged and his condition identified and referred to the physician as is appropriate and in as expedient
a manner as possible

STANDARD 2: If it is necessary that the patient has to wait for care as a result of emergencies or other priorities, the patient will be kept informed as to the reason for die wait

STANDARD 3: Once admitted , the patient's condition will be monitored closely for any changes in condition and his priority in being seen or treated will be changed according to his changing needs.
A review of blood pressure categories defined by the American Heart Association revealed: "a systolic pressure higher than 180 or a diastolic pressure higher than 110 is a hypertensive crises.
Hypertensive crises can present as hypertensive urgency or as a hypertensive emergency.
Hypertensive urgency is a situation where the blood pressure is severely elevated [180 or higher for your systolic pressure (top number) or 110 or higher for your diastolic pressure (bottom number)], but there is no associated organ damage. Those experiencing hypertensive urgency may or may not experience one or more of these symptoms:
? Severe headache
? Shortness of breath
? Nosebleeds
? Severe anxiety
Treatment of hypertensive urgency generally requires readjustment and/or additional dosing of oral medications, but most often does not necessitate hospitalization for rapid blood pressure reduction. A blood pressure reading of 180/110 or greater requires immediate evaluation, because early evaluation of organ function and blood pressure elevations at these levels is critical to determine the appropriate management.

A review of the "Emergency Severity Index (ESI), A Triage Tool for Emergency Department Care" revealed:

"Patients who meet ESI level-2 criteria should have their placement rapidly facilitated. ESI does not specify timeframe to physician evaluation, unlike many other triage systems. However, it is understood that level-2 patients should be evaluated as soon as possible.
The following three questions should be answered and are key components of
ESI level-2 criteria:
? Is this a high-risk situation?
? Is the patient experiencing new onset confusion, lethargy, or disorientation?
? Is the patient experiencing severe pain or distress?

1. Is This a High-Risk Situation?
The ability to recognize a high-risk situation is a critical element of the triage decision-making process, regardless of the triage system used. ESI highlights the importance of recognizing high-risk situations and uses the triage nurse ' s expertise and experience to identify patients at high risk.

Neurological
Patients with severe headache associated with mental status changes, high blood pressure, lethargy, fevers, or a rash should be considered high-risk.

2. Is the Patient Experiencing
New Onset Confusion, Lethargy, or Disorientation?
The second question to consider when determining whether a patient meets level-2 criteria is, " Does the patient have new onset confusion, lethargy, or disorientation? "

3. Is the Patient Experiencing
Severe Pain or Distress?
The third and final question to address when determining whether the patient meets level-2 criteria is, " Is the patient experiencing severe pain or distress? "

Is the Patient in Severe Pain or Distress?
The third question the triage nurse needs to answer at decision point B is whether this patient is currently in pain or distress. If the answer is "no," the triage nurse is able to move to the next step in the algorithm. If the answer is "yes," the triage nurse needs to assess the level of pain or distress. This is determined by clinical observation and/or a self- reported pain rating of 7 or higher on a scale of 0 to10. When patients report pain ratings of 7/10 or greater, the triage nurse may triage the patient as ESI level 2, but is not required to assign a level-2 rating.

Once an ESI level-2 patient is identified, the triage nurse needs to ensure that the patient is cared for in a timely manner. Registration can be completed by a family member or at the bedside. ESI level-2 patients need vital signs and a comprehensive nursing assessment but not necessarily at triage. Placement in the treatment area is a priority and should not be delayed to finish obtaining vital signs or asking additional questions."

An interview with staff #3 the ED Director on 7/25/2014 at approximately 11:30AM in the Administrative Conference Room revealed the facility was actively working to reduce the emergency room wait time. Interviewee revealed wait times were being monitored daily and addresses as needed with the staff. The interviewee revealed that LWOT (left without treatment) were usually due to patients not wanting to wait. The interviewee was asked if the LWOT ' s medical records were being reviewed/audited by the facility. The response was NO.

It was determined that these deficient practices created an Immediate Jeopardy situation, resulting in a likelihood of harm and serious injury to all patients, staff, and visitors.
VIOLATION: EMERGENCY SERVICES POLICIES Tag No: A1104
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the facility failed to enforce the medical Staff Rules and Regulations and the policy titled Medical Screening, Consultations, Treatment, and Transfer Policy. 2 0f 21 patients (patient #18 and #21) did not receive timely medical screening.

A review of the document titled "Medical Staff Rules and Regulations" revealed:
"38. The hospital shall meet the emergency needs of its patients in accordance with the acceptable standards of practice as defined in the Systems Policy and Procedures titled "Medical Screening, Consultation, Treatment and Transfer Policy" (ADM. 1.3.0006).

A review of the document titled "Medical Screening, Consultation, Treatment and Transfer Policy" revealed.... A medical screening examination will be provided to all individuals who come to the emergency department for a medical condition.

Review of patient emergency room record dated 12/21/2013 revealed the following:
Patient #21 arrived at the facility's emergency room on [DATE] at 13:37 (1:37 PM) by way of ambulance. The ambulance service's document titled, Initial Pre-hospital Care Report revealed:

Chief complaint: numbness to right leg
PMS (Past Medical History): hypertension, TIA (transient ischemic attack), Diabetes
Pulse 79, B/P (blood pressure) 179/70, SpO2 (oxygen saturation) 98%
Response to Treatment/Narrative: Pt. (patient) states rt. (right) hand/shoulder started feeling numb yesterday morning. Last night she noticed her rt. leg was going numb and dragging.

A review of the document titled Emergency Nursing Record; Neuro Deficit Complaints revealed:

Triage Date: 12/21/13
Time: 1340
Acuity 3 (ESI)
Historian: Paramedic
Arrival Mode EMS
Vitals: B/P 165/71, P 78, RR (repirations) 16, Temp 98.6, SpO2 97%
Chief Complaint: Right hand/shoulder/leg started 24 hrs ago. Sudden onset numbness yesterday morning. Walking around per EMS.
Past Medical HX:HTN, diabetes, TIA
Blood Sugar 127
Additional Notes: 1430 (2:30PM)- Told reg. clerk she was leaving.
Depart Date 12/21 Time 1430

A review of the document with the titled heading, "Please Fill Out This Form For Each Patient" revealed the patient's demographics:

Date 12/21/13
Time 1:30 PM
Name: patient #21 ....
Reason For This Visit: Stroke

No medical screening was provided to patient #21

A phone interview was conducted with patient #21's sister on 07/24/2014, at approximately 4:00PM. The interview revealed patient #21 was having stroke like symptoms and had called EMS to transport her (patient #21) to the hospital. Patient #21's sister had met the ambulance at the facility. The patient's sister reported she was present when EMS personnel gave report to a nurse. The nurse instructed the EMS personnel to put the patient in a wheel chair and place her in the waiting room. The patient #21 was triaged shortly after being placed in the waiting room. Patient #21 was placed back in the waiting room after being triaged. Patient #21's sister reported that she repeatedly told the registration clerk the patient was getting worse. Patient #21's speech was being affected and was slurring words. The clerk's response was the nurses knew the patient was in the waiting room and would get to her as soon as possible. After waiting approximately an hour in the waiting room, with no response from the ER staff after repeated request for help, the decision was made to seek medical attention at a different facility. The interview revealed patient #21 was admitted to facility #2 with a stroke and placed in ICU.

A review of patient emergency room record dated 06/16/2014 revealed patient #18 arrived at the facility's emergency room at 17:11 (5:11 PM). The Presenting complaint: Patient states: Headache, Blood Pressure evaluated...Care prior to arrival: Has taken blood pressure med and 3 clonidine today.
17:22 Acuity: 3-Urgent (ESI)
Triage Assessment: 17:26 General: Appears well nourished, well groomed. General: Behavior is agitated, anxious. Pain: Complains of pain in Head. Pain currently is 7 out of 10 on a pain scale. Pain began about a week ago.
Vital Signs: 17:20 B/P 191/118, Pulse 112, Resp. 18, Temp 98.5.
18:40 .... Pt. not in waiting room when called to take to a room.
18:59 Patient left the ED.

Patient #18's emergency room medical record revealed a wait time of 1 hour and 29 minutes with no evidence of the patient being re-evaluated. No medical screening was provided to patient #18.