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.

CHRISTUS GOOD SHEPHERD MEDICAL CENTER- LONGVIEW 700 EAST MARSHALL AVENUE LONGVIEW, TX 75601 Nov. 16, 2017
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview, and record review, the facility failed to:

1. ensure there was a sufficient number of Registered nurses (RN's) in the Emergency department (ED) to provide care to patients from 11/01-13/2017.

2. ensure they followed their staffing matrix and staffed nurses for all beds being used. The facility was using hall beds and they were not being included in the staffing numbers.

3. ensure they addressed staffing needs for patient censuses above 145.

Refer to tag A 0392 for additional information.
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
Based on observation, interview, and record review, the facility failed to:

1. ensure there was a sufficient number of Registered nurses (RN's) in the Emergency department (ED) to provide care to patients from 11/01-13/2017.

2. ensure they followed their staffing matrix and staffed nurses for all beds being used. The facility was using hall beds and they were not being included in the staffing numbers.


3. ensure they addressed staffing needs for patient censuses above 145.

This deficient practice had the likelihood to cause harm to all patients presenting to the ED.


Findings include:


During an observation on 11/14/2017 after 10:00 a.m., main campus ED was found to have beds positioned in the hallways throughout the ED.


During an interview on 11/14/2017, after 10:30 a.m., Staff #11 reported the RN (Registered nurse) staffing for the ED was as follows:

8a-8p (9 RNs)
10a-10p (1 additional RN)
11a-11p (2 additional RN's)
4p-4a (1 additional RN)
8p-8a (9 RNs)

During an interview on 11/14/2017, after 10:30 a.m., Staff #10 reported they had a total of 28 ED bays and 2 trauma bays. They did not staff for hall beds, because they did not use them. The nurse to patient ratio was 4:1 and the trauma rooms were staffed 1:1.


Review of the nursing staffing matrix revealed the staffing numbers were based on an average census of 145. There was no documentation of how many Registered nurses (RNs) were allowed above the 145 census on the matrix. The following numbers were listed for allowable Registered nurses (RN) for an average census of 145:

8a-11a 11a-4p 4p-8p 8p-11p 11p-4a 4a-8a

RN 9 10 10 10 9 9

Midshift RN 2 3 3 1

RN Weekend 8 9 9 9 8 8


The RN charge nurse who was not supposed to be taking patients was added into the total number of nurses on the matrix.

The numbers listed on the staffing matrix did not reflect the total of RNs the administrative nursing staff reported they were actually staffing. The numbers of nurses being used was less than what the matrix called for.


Review of nurse staffing from 11/01-13/2017 revealed the ED was short a RN on the following days/nights:

On 11/6/2017 the ED was short by one RN from 8a-8p;

On 11/7, 11/8, 11/9, 11/10, 11/11, and 11/12 the ED was short a midshift RN for the entire shift or a portion of the shift on these days.

On 11/6 the census was 152 and 11/10 there was a census of 158 and there was no increase in the number of RN's to meet the increased patient census.

During an interview on 11/15/2017 after 10:00 a.m., Staff #10 confirmed the numbers.



Review of charge nurse reports from 11/01-14/2017 revealed the following information about nurse staffing:

11/02/17, hall beds B and G were being used and a nurse was assigned to the beds. There was the following documentation" we tried all night to get a sitter for room 26 he is a huge fall risk and really is a 1:1 patient. He is confused and urinates all over the floor. He is gonna hurt himself if we don't find a dispo for him."

11/03/2017, "this pt is supposed to have a 1-on-1 sitter (security guard), as of 3 pm today we did not have this."

11/07/2017, "At 11a, trauma nurses taking hall beds B&C, (nurse) taking Hall G and charging since 0720."

11/11/2017, "(nurse) taking over rooms 13&16 and hall bed F@1300 and charging."

11/12/2017, "One trauma RN all day. 2 sets of rooms shut down 8a-11a, then one set of rooms shut down until 4p."

During an interview on 11/15/2017 after 2:00 p.m., Staff #20 reported that staffing problems had not changed. They were still very short staffed and the charge nurse was having to take patients also. They are having a lot of high acuity patients on most days, new nurses working and having to help them. Sometimes it gets overwhelming.


During an interview on 11/16/2017 after 9:30 a.m., Staff 21 and 22 reported they use the hall beds when they are busy.


During an interview on 11/16/2017 after 9:30 a.m., Staff #15 reported that staffing in the ED was minimal. They were short staffed in nurses.







On 11/15/2017 in the a.m., an interview with ED staff nurse #24, confirmed there were times when all efforts to obtain more staff were exhausted and you just had to "Do what you have to do to take care of your patients". "Managers were working and staff were being added but sometimes you may or may not get help".
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review the facility failed to:


1. ensure 1 of 22 sampled patients received conscious sedation in a safe manner (Patient #15)

Patient #15 (2 year old child) was administered conscious sedation by a registered nurse without a physician present during a Magnetic Resonance Imaging procedure on 04/03/2017.

The facility failed to ensure there was documentation as of 11/16/2017 that all ED nursing staff, radiology staff and physicians received training after the incident occurred.

Refer to tag A 0144 for additional information.








2. follow its established policies for Grievance resolution in 6 of 6 patient grievances reviewed (#1, #2, #3, #4, #5, and #6)

The facility failed to thoroughly investigate grievances, failed to resolve grievances within 7 days, and failed to make notification to the complainant if the investigation would take more than 7 days to resolve.

These grievances involved patients not being assessed timely, appropriate treatment not being provided timely, and rude treatment from facility staff.

Refer to tag A 0122 for additional information.
VIOLATION: PATIENT RIGHTS: GRIEVANCE REVIEW TIME FRAMES Tag No: A0122
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on document review and interview the facility's policy failed to include a time frame for resolution and notification to patients when a complaint/grievance was resolved in 4 of 4 compliant. (patient's #1, #2, #3, and #4)

This deficient practice had the likelihood to effect all patients of the hospital.


Findings included.


On 11/16/2017 at 9:00 AM a sample of 4 patients (Pt's #1, #2, #3, and #4) who had filed complaints, were reviewed in the presence of the Risk manager, staff # 9.

Pt #1: Pt #1 came to the ED on 11/7/2017 at 10:15. At 11:10, he was triaged and placed in room #10 at 11:17. Initial assessment was completed by the PA (Physician's Assistant) at 11:50. Pt was administered Motrin 400 mg, Norco 10-325 mg and Bactrim160-800 mg (DS-double strength) at 12:10. PA ordered consent for I&D (incision and drainage) at 12:05. At 14:09, pt. reported to nurse that he was tired of waiting for I&D procedure and was leaving....

Staff #28 placed a call to patient #1 at his home as a follow-up to the complaint. He retold the above sequence of events.

The recommendation from the nurse who investigated the incident was to refer the PA to the ED Medical Director. End of report. There was no resolution documented or follow-up recorded for this grievance. There was no evidence the ED Medical Director acted on the request from Staff #28.

This was categorized as a complaint, even though it did not meet the definition of a complaint and the patient left and the resolution occurred after the patients departure from the hospital. The complaint was closed 11/10/2017. No patient letter was attached for review.


Pt #2: Review of documentation dated 11/3/2017 5:14 PM by staff #28. Pt #2's grievance was noted as a "complaint". Pt #2 "called me with a complaint from July 12 ER (emergency room ) visit pt #2 had a infection and she told the nurse that she does not need a self-administered ointment because it does no good to use because she needs something to work from inside her body to heal her sore. The nurse did not listen to her and still billed her for the ointment for $15.06...." A summary of the complaint revealed upon return to the ED for staple removal, a staple was left in the suture line and became sore and was difficult to remove by her primary care physician. The remainder of the grievance was not related to the hospital ED visit.

Review of the grievance resolution dated 11/8/2017 written by staff #11 revealed Pt #2 came to the ED 7/12/2017 after she suffered a fall which resulted in a laceration in her scalp which required staples. "Neosporin was applied by the nurse as part of her wound care in the ED with staples. Extra Neosporin may have been sent home with the patient as it is a one-time single use packet and would otherwise be thrown away. Pt given prescription for antibiotic (Keflex 500 mg) on discharge. Pt did not return to ED for staple removal. Last ED visit was on 7/12/2017 when staples were placed".

This was categorized as a Complaint and was closed 11/10/2017. This patient voiced that she did not want Neosporin applied to her wound. The Neosporin was applied and the extra Neosporin, from the single use application packet, was handed to the patient. No patient letter was included for review. This compliant/grievance was not made known to the staff until after the patient was discharged .


Pt #3: A review of the 11/5/2017 event was documented as received on 11/6/2017. The "complaint" was investigated on 11/8/2017.
Pt #3 was a [AGE] year old male, brought by ambulance to the hospital Ed for elevated blood sugar. The family complained when they came to the ED to locate their grandson they spoke with a male staff member who denied pt #3 was in the ED and was rude to the family. An ambulance driver came and gave the family a report on their grandson and told them where he was in the ED. The grandmother approached the male staff member (registration desk?) to get a pass to enter the treatment area of the ED to see her grandson. The male staff refused the pass and "screamed at them and the whole ER could hear him screaming I don't have this person in ER". After the grandmother explained again, the staff member found the boy in the computer." The patient's concern was for the rudeness of the staff to her and others in the waiting area.

There was no documentation of investigation with the male staff and no resolution to indicate this staff behavior would not occur again in the ED.

The status was listed as open with a 11/10/2017 follow-up date given.


Pt #4: The event was listed as a complaint which occurred 10/29/2017 and was made known to the hospital on [DATE]. Staff #11 documented the status was closed on 11/9/2017.

The documentation of the event was reviewed. "Pt had labs collected at Triage due to prolonged wait time. RN did not review chart prior to going into greet the patient and did not see that labs had already been collected, no recollection was done, results were correctly posted to patient's chart. Pt returned on 11/4 and was discharged ".

Staff #28 had documented the receipt of the complaint in writing via email. The complaint read as follows: "I brought my daughter in the emergency room and this has been the longest wait that I've ever had. We were here before 12 PM and it's now 4:03 and we are just getting to a room the triage department had gotten my daughter's blood and urine sample, and when the nurse comes in our room the first thing she says is she needs a blood and urine sample. We had to let her know that they had already done these things and that this is ridicoulous (sic)that they don't know what all had been done to the patient at there (sic) hospital. this has been very time consuming annoying frustrating, (sic) and we still sit here starving because we didn't get to eat lunch because we were still sitting in here at hospital (sic)...".

No investigation or resolution was documented. There was no explanation for the prolonged wait time. There was no evidence the system that was used to collect lab samples from pt's who were triaged, prior to patient being placed in an ED room, had been reviewed. The staff were made aware of this grievance after they were discharged for m the ED.

This complaint was closed 11/10/2017. The patient letter sent 11/2/2017 read in part, "... We appreciate you bringing your concerns to our attention, allowing us the opportunity to review our practice and respond. ...We expect all health care providers to treat patients with respect and consideration.... we want to assure you that the responsible administration staff has taken appropriate follow up action with the employee."

There was no evidence documented on the grievance report that action had been taken by administrative staff with the employee.



Review of the facilities "Grievance" policy revealed "It is the policy of this hospital to implement an effective system to address concerns about any aspect of care or service.

3. "Reporting grievances: Any written or verbal Patient complaint that cannot be promptly resolved by the staff member (s) present shall be referred to the Patients Relations Specialist."

5. ii. Investigation: The Patient Relations Specialist staff may include others as necessary in the investigation of the Patient Grievance. The the extent possible, the Grievant and the patient (when the patient is not the Grievant) should be contacted as part of the investigation and attempts to resolve the issue should be made.

6. ii Timeliness: Most grievance should be completed within seven days of receipt. If however, it will take more than seven days to conclude the investigation, the Grievant shall be notified and an approximate date of resolution (generally within 30-45 days) communicated to the Grievant.

6. iii. At the conclusion of the investigation, the Grievant shall be sent a letter briefly describing the conclusions of the investigation and, when appropriate, the steps taken to resolve the matter."
VIOLATION: PATIENT RIGHTS: CARE IN SAFE SETTING Tag No: A0144
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review the facility failed to ensure 1 of 22 sampled patients received conscious sedation in a safe manner (Patient #15).

Patient #15 (2 year old child) was administered conscious sedation by a registered nurse without a physician present during a Magnetic Resonance Imaging procedure on 04/03/2017.

The facility failed to ensure there was documentation as of 11/16/2017 that all ED nursing staff, radiology staff and physicians received training after the incident occurred.

This deficient practice had the likelihood to cause harm to all patients who presented to the ED who required conscious sedation.


Findings include:


Review of an ED record on Patient #15 revealed he was a 2 year old male patient who (MDS) dated [DATE] at 3:10 p.m.. Patient #15 presented with complaints of a head injury after a fall.

At 3:33 p.m., Patient #15 was given an acuity level of 4 (Semi-Urgent).

At 4:38 p.m., the medical screening was complete.

At 6:06 p.m., a physician's order was written for a MRI (Magnetic Resonance Imaging) for a possible subdural bleed.

At 8:50 p.m., a verbal physician's order was written for the sedative agent "Ketamine1mg/kg IVP once, Administer by physician." Verbal Order: 04/03 20:50 (by Staff nurse #20 for Physician #27) ...Administered: 04/03 21:18 by (Staff nurse #20)

According to documentation in the nursing notes the procedure started at 9:18 p.m..

There was documentation at 9:18 p.m. of the following; "Ketamine 1 mg/kg {Note: 15 MG: ADMINISTERED BY DR. (#27)} Route IVP;" The entry was signed off by (Staff nurse #20); Frequency once..."


According to the nurses notes the procedure ended at 9:30 p.m..

According to a variance report dated 04/04/2017 the incident occurred 04/03/2017 at 9:00 p.m... There was documentation that Staff #16, "MRI tech was called in for a patient needed MRI of Brain with anesthesia. The anesthesiologist was in a heart case, so, he could not come. (Physician #27) proceeded to order conscious sedation on the patient. An ER nurse came to MRI and administered the medication. No dr. or radiologist was present in the MRI suite while the sedation took place in the MRI suite."

There were corrections made to the charting at 10:00 p.m. and the following was listed:

At 10:03 p.m., 9:18 p.m. "Ketamine 1mg/kg IVP" signed off by Staff nurse #20.


During an interview on 11/16/2017 after 10:00 a.m., Staff #16 (Radiology technician) confirmed he was the staff in MRI and the nurse administered the anesthetic agent. There was no physician present. Staff #16 confirmed there had been no directive or changes from his supervisor (Staff #19) after the incident.

During an interview on 11/16/2017 after 11:15 a.m., the following was reported:

Staff 19 (Director of Radiology) confirmed he had not implemented any new systems to ensure his staff would not participate in such a procedure again. Staff #19 confirmed he had not in-serviced his staff.

Staff #10 (Director of ED) provided an April 2017 staff meeting where they talked to ED nurses about administration of conscious sedation. Twenty nine (29) out of sixty one (61) staff signed as receiving the training. There was no documentation that all of the nurses received the training. Staff #10 confirmed the missing signatures on the form.

Physician#18 (ED Medical director) provided documentation of minutes from meetings to physicians about conscious sedation administration for 06/07/17 and 8/02/17.

Physician #18 confirmed he talked to the physicians, but could not provide any documentation of who received the information.




Review of the facility's policy named "Provision of Anesthesia Services" dated 10/28/2016 revealed the following:

"Moderate sedation/analgesia :( Conscious Sedation) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

PROVISION OF MODERATE SEDATION

Physically Administering a Sedating Agent

..The mechanical act of administering moderate sedation may only be performed by licensed staff, consistent with scope of practice, professional standards, and demonstrated competency.

Provision of Personnel

Sufficient numbers of qualified personnel (in addition to the practitioner performing the procedure) should be present during procedures using moderate sedation to:

Appropriately evaluate the patient prior to administration of moderate sedation
Provide the moderate sedation
Perform the procedure
Monitor the patient, and
Recover and discharge the patient"
VIOLATION: ORGANIZATION AND DIRECTION Tag No: A1101
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on observation, interview, and record review, the facility failed to:

1. ensure ED (Emergency department) patients were accurately assessed for fall risk.

2. ensure interventions were implemented and implemented timely for ED patients at high risk for falls.

3. ensure ED nursing staff had a fall policy in place to assist with determining fall risk factors and interventions.


This deficient practice was found in 8 of 22 sampled patients (Patient #'s 7, 8, 9, 11, 16, 18, 19, and 22). These deficient practices resulted in Patient #7 and 16 sustaining fractures after falls in the ED.


Patient #7 was provided fall interventions that did not include toileting the patient since she was drowsy and could not ambulate alone. The call light was provided for someone who was described as not being fully oriented and drowsy.


Patient #16's age, diagnosis of seizures and mental status put him at an increased risk for fall which was not identified during the initial assessment.


This deficient practice had the likelihood to cause harm to all patients who presented to the ED.


Findings include:


Review of the ED record on Patient #19 revealed he was a [AGE] year old male who (MDS) dated [DATE] at 6:40 p.m. with complaints of chest pain.

Review of documentation at 6:51 p.m., revealed Patient #19 had a history of myocardial infarction, asthma, cerebral vascular accident, hypertension, chronic obstructive pulmonary disease and congestive heart failure. Patient #19 was given two Nitro tablets in route to the ED.

At 6:56 p.m., Patient #19 was described as having a pain level of 8 out of 10 (0 being no pain and 10 being severe pain).

Review of medication administration documentation revealed at 7:22 p.m., Patient #19 was given a vasodilator Nitro-Dur patch and the pain medication Morphine via IV (intravenously).

Review of a fall risk assessment performed at 7:26 p.m., revealed Patient #19 had no risks identified.

Patient #19's diagnoses, pain level, vasodilator medication, and pain medication all put him at an increased risk for falls which were not identified.




Review of the ED record on Patient #16 revealed he was a [AGE] year old male who (MDS) dated [DATE] at 7:43 a.m. with a possible seizure.

At 7:45 a.m., there was documentation that the side rails were up times two and Patient #16 was on seizure precautions. Patient #16 was described as being drowsy by nursing staff.

At 7:54 a.m., a triage assessment revealed Patient #16 was awake and alert. The patient was oriented to person, place, and not oriented to date. There was also documentation that Patient #16 had a history of a closed head injury.

Review of a fall risk assessment performed at 7:54 a.m., revealed Patient #16 had no risks identified.

At 8:17 a.m., the following was documented;

"PRIMARY RN WALKED BY ROOM AND PT WAS ON THE FLOOR LYING ON RIGHT SIDE ACTIVELY SEIZING. BOTH SIDE RAILS WERE STILL UP WITH CALL LIGHT ON RIGHT SIDE RAIL AND PADDING ON BOTH SIDE RAILS STILL IN PLACE. DR ... WAS RIGHT BEHIND PRIMARY RN AND WITNESSED THE EVENT. PAT'S HEAD HELD TO AVOID FURTHER HEAD TRAUMA UNTIL PT STOPPED SEIZING PT THEREAFTER WAS POST ICTAL WITH SNORING RESPIRATIONS. PLACED BACK IN BED, OXYGEN ADMINISTERED VIA 2LNC, AND SEIZURE MEDICATION ADMINISTERED & 822 PER DR ...VERBAL ORDER SEIZURES PRECAUTIONS IN PLACE, CALL LIGHT IN REACH AND PT. TRANSPORTED TO CT WILL CONTINUE TO MONITOR PT."

At 10:09 a.m., "CRN MADE AWARE THAT PT NEEDS A SITTER D/T FALL RISK."

At 12:20 p.m., "CALLED STAFFING TO FOLLOWUP ON REQUESTED SITTER, STATE WE WILL NOT HAVE A SITTER UNTIL 1500 (3:00 P.M.) TODAY.

At 12:58 p.m., ": BH CLINICAL DIRECTOR TO BEDSIDE TO SIT WITH PT"


Review of the CT scan of the head dated 07/11/2017 revealed the following results:

Indications: "Confusion/Altered Mental Status SEIZURE TODAY WITH FALL FROM BED"

"Subtle nondisplaced fracture right frontal bone extending into the superior orbital wall. Associated overlying frontal scalp and supraorbital soft tissue hematoma."

During an interview on 11/15/2017 after 10:00 a.m., Staff #9 reported that Patient #16 was found to have an orbital fracture and that this fall was not listed on the variance log. Staff #9 and Staff #10 confirmed the problems with the fall assessment.

Staff #10 revealed Patient #16 had already gotten up once while in Room #13. Patient #16 did not have a bed alarm on. Staff #10 reported they moved Patient #16 to Hall bed G and provided education. When questioned about how nurses determined how the patients were at high risk for falls, Staff #10 reported not knowing what their guidelines were. Nurses could use their nursing judgement to determine when a sitter was needed to be put into place.

Patient #16's age, diagnosis of seizures and mental status put him at an increased risk for fall which was not identified during the initial assessment.



Review of the ED record on Patient #7 revealed she was a [AGE] year old female who (MDS) dated [DATE] at 12:36 p.m., with complaints of fall injury, hematoma to left forehead and shoulder pain.

Review of the triage assessment at 12:55 p.m., revealed Patient #7 was drowsy, oriented to person and her speech was slurred. The following was documented underneath the fall assessment:

"Fall Risk: Patient is at higher risk due to fall injury within last 3 months, inability to understand instructions. Patient is at higher risk due to fall injury within last 3 months, age, decreased mobility, requires 2 people to assist with ambulation, weakness, inability to understand instructions. Fall risk Interventions: ED Physician notified, side rails up, patient placed near nurses' station. CALL LIGHT IN REACH."

At 1:05 p.m., nursing documented that Patient #7 had "correct armband on for positive identification. Bed in low position. Call light in reach. Side rails up x 2."

At 2:53 p.m., the following was documented:

"RN CALLED TO ROOM FOR PT FALLING OUT THE BED WITH BOTH SIDE RAILS STILL BEING UP. UPON BEING CALLED TO ROOM PT NOTED TO BE LYING ON THE FLOOR C/O PAIN ALL OVER AND CRYING. PT NOTED TO BE SATURATED IN URINE AS WELL. PT PLACED ON BACKBOARD AND PLACED BACK ON BED. BOTH SIDE RAILS UP YET AGAIN. MD CALLED TO ROOM TO ASSESS PT. PT NOTED TO NOT WANTING TO LIE ON THE LEFT HIP. C/O SEVERE PAIN IN LEFT HIP, HIP NOTED TO HAVE DEFORMITY TO LEFT HIP. PT STATES SHE CRAWLED TO THE EDGE OF THE BED TO GET UP TO GO PEE WHEN SHE fell UPON STANDING. NO OTHER BRUISES OR ABRASIONS NOTED.

At 2:57 p.m., "PT TRANSPORTED TO CT SCAN. "

At 2:58 p.m., "Patient has correct armband on for positive identification. Bed in low position. Call light in reach. Side rails up X 2."


At 2:59 p.m., "SITTER AT BEDSIDE WITH PT. "



Review of the CT scan of the head dated 07/21/2017 revealed the following results:

Indications: "GLF (ground level fall) today W (with) HEAD INJURY, left hip pain ..."

"CONCLUSION: Impacted left femoral neck fracture. Moderate superior displacement of distal fracture fragment."

Patient #7 was provided fall interventions that did not include toileting the patient since she was drowsy and could not ambulate alone. The call light was provided for someone who was described as not being fully oriented and drowsy.

During an interview on 11/14/2017 after 2:00 p.m., Staff #10 confirmed there was no system for distinguishing between high, medium and low fall risk. They were using the Morse scale, but that was removed in August of 2016. The fall committee had met on last week, but they had not implemented anything yet.




Review of the ED record on Patient #8 revealed he was a [AGE] year old male who (MDS) dated [DATE] at 11:36 p.m., with a diagnosis of upper gastrointestinal bleeding. At 11:47 p.m., Patient #8 was described as having pain in the abdomen and in the left foot.

Review of a fall risk assessment performed at 11:36 p.m. and 11:47 p.m., revealed Patient #8 had no risks identified.

At 11:59 p.m., an x-ray was performed on the left foot and at 00:55 the results were an "OBLIQUE 5TH METARTARSAL FRACTURE."

Review of nurse's notes dated 09/07/2017 at 7:30 a.m., Patient #8 was documented as having a hematoma to the left upper eye. The patient had a laceration to the forehead.

Review of nurses notes dated 09/07/2017 at 7:42 a.m., Patient #8 was found in bed bleeding noted to forehead,"pt states he got up out of bed and fell on to the floor. Pt was told multiple times to not get out of bed without assistance but got up anyway. Pt cleaned of blood, pt urinated on floor, room cleaned of urine linens changed ... ....er doc notified ...ct of head and neck ordered ..."

According to physician documentation on 09/07/2017 at 8:40 a.m., revealed they were notified that the patient fell out of bed. They would order a CT (computed tomography) and would be followed by the hospitalist.

On 09/07/2017 at 1:04 p.m., there was documentation of Patient #8 having a wound repair of a 4 cm (1.6 in) full thickness laceration to middle aspect of left eyebrow and outer aspect of left eyebrow. Irregularly shaped ...

Patient #8's age, gastrointestinal bleeding, pain and fractured toe all put him at an increased risk for fall. When Patient #8 fell it increased his risk more and the fall risk assessment was still not changed or updated.



Review of the clinical record of Patient #9 revealed she was an [AGE] year old who (MDS) dated [DATE] at 2:52 p.m. with complaints of heart palpitations and atrial fibrillation.

Review of a fall risk assessment performed at 3:07 p.m., revealed Patient #9 had no risks identified.

At 6:20 p.m., Patient #9 was given the heart medication Sotalol.

According to www.drugs.com/sfx/sotalol-side-effects.html, some of the most common side effects with usage of this medication are:

blurred vision
chest pain or discomfort
confusion
difficult or labored breathing
dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position
fast, slow, irregular, pounding or racing heart beat or pulse
lightheadedness, dizziness, or fainting ...

At 6:30 pm., nurses documented that Patient #9 fell in the bathroom. Patient stated "she doesn't know why she fell . she thinks she slipped or something. I stood up to pull the call light and fell backwards." Patient thinks she has some mild pain in her occipital region. She also states she falls al lot. Patient denies any further injuries and reports no LOC or dizziness. Patient was in slippers and shown the call light before the incident ...MD notified. CT scan ordered."

Patient #9 heart condition, age and administration of the heart medication put her at an increased risk for falls which was not identified on presentation.




Review of an ED record on Patient #11 revealed she was a [AGE] year old female who (MDS) dated [DATE] at 4:48 p.m., with complaints of uncontrollable movement and slurred speech.

Review of the history revealed Patient #11 had a history of chronic obstructive pulmonary disease, hypertension and seizures.

Review of a fall risk assessment performed at 4:48 p.m., revealed the following:

"Fall Risk: Patient is at higher risk due to age, weakness, Fall Interventions: ED Physician notified, side rails up."

There was another entry for 4:48 p.m., where it was documented that "Patient has correct armband on for positive identification. Bed in low position. Call light in reach. Siderails up X 2. Adult w/patient. Seizures precautions initiated ..."

At 8:00 p.m., there was documentation in nurses notes that revealed the following:

"RN instructed pt to stay in bed and use call light when needing to get out of bed. Staff member walked by room and found pt on floor in room. Upon assessment of pt, new lac found over right eye. Pt states she tried to use call light but it did not work. RN tested call light and it did not work. MD notified and will set up for lac repair. Charge nurse notified and work order put in for call light. RN passed room several time with door open, pt seen sleeping comfortably in bed."




Review of the ED record of Patient #18 revealed he was a [AGE] year old male who (MDS) dated [DATE] at 6:31 p.m.. Patient #18 complained that "Around 430 this afternoon I got really confused after leaving target while I was driving and ran a stop sign. I went to hospitality ER and they did a CT and wanted to drive me here in an ambulance but I told my wife to take me. My blood pressure is really high and I'm having trouble getting my words out."

Review of a fall risk assessment performed at 6:32 p.m., revealed Patient #18 had no risk identified.

At 6:39 p.m., the CT Head Stroke Protocol was ordered.

At 6: 40 p.m., Patient #18's blood pressure was documented as being elevated at 196/116.

At 6:50 p.m., Patient #18 was given an anti-anxiety agent Lorazepam.

Patient #18's elevated blood pressure, possible stroke symptoms described on admission, and the administration of the anti-anxiety agent all put the patient at high risk for falls, which was not identified.

Staff #10 confirmed the problems with the fall assessments.




Review of the ED record on Patient #22 revealed he was a [AGE] year old male who (MDS) dated [DATE] at 7:50 a.m. with complaints of being combative and possible seizure activity. Patient #22 was given an injection of the anesthetic agent Ketamine prior to being transferred to the hospital.

According to the triage assessment at 7:59 a.m., Patient #22's level of consciousness was described as being lethargic.
Patient #22 was described as having a history of seizures and bilateral below the knee amputations.

Review of a fall risk assessment performed at 7:59 p.m., Patient #22 was at higher risk for falls due to the inability to understand instructions and possible drug use. There was no documentation of what fall interventions nursing were implementing nor implementation of seizure precautions.

During an observation on 11/16/2017 after 9:20 a.m., Staff #25 (a nursing student) was observed telling staff members in the hallway that Patient #22 was coming out of the bed. Patient #22 was observed in a bed that had full side rails that were up on both sides and he was hanging off the edge of the mattress at the foot of the bed.

Staff #10 and 22 confirmed the observation.



Review of a facility policy named "Fall Prevention" dated July 28, 2017 revealed the following:

"Guidelines

Patients at enhanced risk for falling will have strategies outlined to develop individualized plans of care to reduce falls and fall-related injuries.

Process:
A comprehensive fall risk assessment should be completed on all patients following admission to any inpatient unit. All other areas, including ambulatory and clinic environments, are determined to be minimal risk of harm from fall with individual patient fall assessment not required.

Should patients receiving care in ambulatory/clinic environments (or low acuity ambulatory ED patients) present as unsteady or otherwise at risk for fall, a fall assessment is not required, however staff should provide safety measures to protect the patient during the clinical encounter."

The policy did not address fall precaution interventions for ED patients. The policy only addressed in-patients who were at risk for falls.
VIOLATION: QUALIFIED EMERGENCY SERVICES PERSONNEL Tag No: A1112
Based on interview and document review, the facility failed to:

A .provide evidence of training for annual skills training for conscious sedation for emergency department nursing staff in 3 (#13, #20 and #23) of 4 (#24) Emergency Department staff,

B. maintain quarterly attendance records for staff meetings where education was included for emergency department staff for 29 of 61 emergency department staff present,

C. failed to provide evidence of education of RN staff and include a comprehensive fall reduction policy that included the ED population. in 4 (#8, #16, #19 and #21) of 7 (#8, #15, #16, #17, #19, #20 and #21) variance reports.


This deficient practice had the likelihood to effect all patients of the hospital's emergency department.


Findings included:


A. On 11/15/2017 review of a competencies for four staff RN's, (#13, #20, #23 and #24), who were emergency department (ED) staff in good standing and scheduled to work, were reviewed. Staff RN's #13, #20 and #23 were identified without current competencies in conscious sedation.


Staff #13:
A document titled, "Conscious Sedation Competency" was not signed by staff #13 however, it was signed by two separate RN evaluators dated 5/24/2002 indicating competency for staff #13. Staff #13's most recent documentation of ED skills competencies were found on a document with the date of 10/08.


Staff #20:
A document that was most recently dated 5/2016 was provided as evidence of skill completion for staff RN #20. Competencies were 6 months past due.


Staff #23:
Staff #23 was an ED staff nurse on the main campus ED. Staff #23's name appeared on a document titled "Annual competency Review" The document was not signed and dated by the employee, Staff #23. The evaluator was not identified by name and no date or signature was found on the document to identify the evaluator.

An interview with the ED supervisor, staff #10 confirmed the above findings. Staff #10 further confirmed no annual competency existed for staff who had been established as competent to administer conscious sedation. The ED Supervisor confirmed the 10/2002 date for most recent competency for staff #13 was correct.

A request was made to review the hospitals policy for annual competencies. No policy was made available for review.




B. A review of quarterly staff meetings conducted by staff #10 revealed two (2) quarterly staff meetings had been documented and submitted for review. Of the 80 names of nursing staff submitted, , 27 signatures were present as evidence a staff meeting was held. This represented 34 % of the staff were present to receive education. The ED supervisor, staff #10 confirmed no attempt was made to provide the meeting information to staff who were not present for the original meetings for the first and second quarters of the year 2017. A request was made to review the hospitals policy for attending staff meetings. No policy was provided for review.


First Quarter:
1. The staff meeting for the first quarter of the year 2017 was dated "April 2017". Signatures of attendance reflected, 29 of 80 staff attended the staff meeting.

Subjects discussed during this meeting was documented as:
Communication with patients.
Documentation of Pain assessment.
Documentation of Medication follow-up.
Documentation of vitals signs, with medications as appropriate and on discharge.
Documentation of home medications.


Second Quarter:
2. The staff meeting for the second quarter of the year 2017 was dated "August 2017". Signatures of attendance reflect 27 of 80 staff attended the meeting.

Subjects discussed during this meeting was documented as:
Service goals.
Finance goals.
Quality goals.
Dress Code.



C. On 11/16/2017 at 9:00 AM a sample (#8, #15, #16, #17, #19, #20 and #21) of patient (Pt/pt) variances were reviewed in the presence of the Risk manager, staff # 9.

Pt #8:
Suffered an unwitnessed fall 9/7/ , with a laceration to his forehead. The variance report indicated "Side rails were up times 2". Facility documentation did not record the investigation as to what might have contributed to the fall. If the side rails were actually necessary or if other falls risk prevention had been attempted.


Pt #16:
Suffered a fall on 7/11/2017. "Active fall with seizure". The documentation failed to identify investigation of previous seizure activity. No determination as to whether the fall/seizure could have been anticipated or avoided.


Pt #19:
Suffered a fall on 2/18/2017. The documentation indicated "environmental care needs" Pt #19 fell after the sitter assigned to him was directed to another location. The documentation failed to reflect investigation as to why the sitter was pulled from pt #19 without another sitter being replaced.


Pt #21:
Suffered a fall in the Radiology department when she was left unattended by the staff. The corrective action did not address the system wide issue of why patients might be left unattended in Radiology.


An interview with staff #9 confirmed the investigations did not reflect whether the patient was inpatient or non-inpatient and did not include system changes for future pt safety related to falls and how they would be implemented.


Review of the facilities "Fall Prevention" policy revealed the policy guidelines included: "Patients at enhanced risk for falling will have strategies outlines to develop individualized plans of care to reduce falls and fall related injuries."

The policy process addressed:
"A comprehensive fall risk assessment should be completed on all patients following admission to any inpatient unit. All other areas, including ambulatory and clinic environments, are determined to be minimal risk of harm from fall with individual patient fall assessment not required.

Should patients receiving care in ambulatory/clinic environments (or low acuity ambulatory emergency department patients) present as unsteady or otherwise at risk of falls, a fall assessment is not required, however, staff should provide safety measures to protect the patient during the clinic encounter."

An interview with staff #26, the RN who was working on the re-evaluation of the fall risk policy confirmed the policy applied to inpatient status. Further the policy did not include the emergency department (ED) patient population. There was no education provided for ED staff who met patient care needs, and no policy which supported fall risk reduction for the ED population.
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on observation, interview and record review the facility failed to:

1. ensure ED (Emergency department) patients were accurately assessed for fall risk.

2. ensure interventions were implemented and implemented timely for ED patients at high risk for falls.

3. ensure ED nursing staff had a fall policy in place to assist with determining fall risk factors and interventions.

This deficient practice was found in 8 of 22 sampled patients (Patient #'s 7, 8, 9, 11, 16, 18, 19 and 22). These deficient practices resulted in Patient #7 and 16 sustaining fractures after falls in the ED.


Patient #7 was provided fall interventions that did not include toileting the patient since she was drowsy and could not ambulate alone. The call light was provided for someone who was described as not being fully oriented and drowsy.


Patient #16's age, diagnosis of seizures and mental status put him at an increased risk for fall which was not identified during the initial assessment.

Refer to tag A 1101 for additional information.







4. ensure there was evidence of annual skills training for emergency department nursing staff in 3 (#13, #20 and #23) of 4 (#24) Emergency Department staff,

Review of competencies revealed Staff RN's #13, #20 and #23 were identified without current competencies in conscious sedation.


5. ensure quarterly attendance in staff meetings was documented where education was being provided for 29 of 61 emergency department staff after an incident involving inappropriate administration of conscious sedation.



6. ensure there was evidence of education on fall assessment and prevention in 4 of 4 (#13, #20, #23 and #24) ED RN's personnel files reviewed.


Refer to tag A 1112 for additional information.