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.

MCLAREN MACOMB 1000 HARRINGTON BLVD MOUNT CLEMENS, MI 48043 Feb. 22, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and document review the facility failed to protect the rights of one of one discharged patients reviewed for sexual abuse out of a total sample of 17, resulting in the potential for undetected, uncorrected abuse with the potential to affect all 224 patients in the facility. findings include:

Findings include:
---the facility failed to document, investigate and report/respond to an allegation of sexual abuse (See A-145)
VIOLATION: PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT Tag No: A0145
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the facility failed to document, investigate, report and respond to an allegation of sexual abuse for one (#10) of one patients reviewed for abuse out of a total sample of 17, resulting in the potential for undetected, uncorrected abuse with the potential to effect all 224 patients in the facility. Findings include:

On 2/21/18 at 0900 through 2/22/18 at 1600, an investigation was conducted at the facility into Patient #10's allegation that she was sexually abused by staff while an inpatient at the facility.

On 2/21/18 at 0930, The Medical Director, Staff I was requested to provide a list of all abuse investigations conducted by the facility in the past six months. Staff I stated that the only abuse allegation in the past 12 months was made by Patient #10, a resident of a nursing home (SNF), who was treated in the facility for Metabolic [DIAGNOSES REDACTED] (brain injury) and infection. The facility investigation into Patient #10's abuse allegation and all corrective measures, reports, Quality and Safety committee reporting was requested at this time.

On 2/22/18 at approximately 0900, review of the facility provided Adverse Event Report log, revealed only one adverse event was documented from 12/31/17 through 2/21/18, a patient fall

On 2/22/18 at approximately 0900, Staff I provided a copy of the police file number into Patient #10's allegation of sexual abuse at the facility, dated 1/4/18, with the assigned Detective's contact information. Staff I was interviewed at this time and reported that he had conducted the facility investigation into Patient #10's allegation that she was sexually abused in the facility. Staff I stated that the facility investigation concluded that the allegation was unsubstantiated, as the patient's allegations were not credible. Staff I stated that the patient had alleged that she was abused by three female staff and one male staff in the hospital stairwell. Staff I stated that Patient #1 was nonambulatory, so the allegation was not credible. Staff I stated that Patient #1 was a nursing home resident with impaired memory and was delirious during her hospitalization due to her medical condition. Staff I stated,"I was the administrator on call when a nursing supervisor called, it was night shift. She said that a family member had approached the nurse and said that someone had sexually assaulted her (Patient #1) in a stairwell. The Nursing Supervisor did call the Sheriff. I did give the sheriff a list of all employees who cared for (Patient #10) and all who were working on her unit. At this time, Staff I was requested to provide the facility documentation of the investigation into patient #10's allegation of sexual abuse and the name of the nursing supervisor who had reported the allegation.

On 2/22/18 at approximately 1025, per second request to provide documentation of the facility's investigation into Patient #10's allegation of sexual abuse, Staff I stated, "I did the investigation myself, and I'm sorry, I know I should have, but I didn't document it." Staff I stated that he did not complete an incident/ Adverse Event Report or notify the Police or the State. Staff I, "The victim did call the police directly. We did give the police a list of concerned employees." Staff I stated that the Human Resources Director, (Staff B) contacted him on 1/4/18 to tell him that the police were there with a warrant to obtain Patient#1's medical record and a list of facility staff who had cared for her during her stay at the facility. At this time, the list of concerned employees provided to the police was requested for review. When asked if the facility had done any staff interviews, or looked at any security camera footage of hallways on the units where Patient #10 was, Staff I stated, "No, the police were going to handle that."

On 2/22/18 at approximately 1025, Detective U, the police officer assigned to investigate Patient #10's allegation of sexual abuse, was interviewed by telephone. Detective U stated, "It was a complaint made by the victim, not the hospital. We took the report on 1/3/18. It is currently an open investigation. The hospital did provide a list of concerned employees, but we haven't interviewed any of them yet. We don't have a good positive ID (identification) from the victim. The only facility employees I talked to were the Administrator (Staff I) and the head of Security (Staff D). We haven't given any them information beyond the fact that there was an alleged sexual assault complaint." When asked if Patient #10 reported that the assault took place in a stairwell, Officer U stated, "She did not give a specific location, but stated that she was laying down in a large room with curtains all around her bed and people outside the curtains."

On 2/22/18 at approximately 1115, the Quality Manager, Staff V was interviewed regarding Patient #10 's abuse allegation, and reported that there was no Adverse Event Report or Incident Report for the Allegation, and that no abuse investigation had been done. Staff W stated, "Our Compliance Director, (Staff W) would have handled it, but this one was tricky because there was already a criminal investigation. When asked, Staff W reported that the allegation was not documented or brought to the attention of either the Safety or Quality committees.

On 2/22/18 at approximately 1150, The Compliance Director, Staff W was interviewed, and stated, "I received a call on 1/3/18 from one of our Social Workers who had received a call from (SNF), where (Patient #10) was a resident. The Social Worker told me that (SNF) had reported to the police that (Patient #10) had reported that she was assaulted while she was here. The Social Worker told me that the Patient said there were three females and one male in the room at the time of the alleged assault. The Social Worker did not fill out an incident report or report it to the Police or the State. I didn't either. I should have. It was a mistake on my part. It is the policy. I am truly embarrassed. I contacted the Administrator (Staff I), the Director of Social Work, and Corporate Risk Management about it (the allegation of sexual abuse in the facility). They probably assumed that I filled out a (Incident report) and reported it to the Police and the State. I did interview the victim's son, but no staff, but didn't document the interview officially."

On 2/22/18 at approximately 1130, Patient #10's clinical record was reviewed and revealed the following: A face sheet documented that Patient #10 was a [AGE] year old female who was transferred to the Emergency Department (ED) from a SNF on 12/14/17 at 0844 with a complaints of increased confusion.

An ED Physician's summary report dated 12/14/17 (no time indicated) documented that Patient #10 was bed-bound and confused, and was diagnosed with [DIAGNOSES REDACTED]

The Nursing "Ambulatory Assessment History Report" documented that Patient #10's ED Nursing Assessment was started by Staff Nurse GG on 12/14/17 at 0902, and completed by Staff Nurse Z at 1018. The documentation noted that an indwelling urinary catheter was inserted by Staff Z (a male) on 12/14/17 at 1018. There were no nursing documentation for Patient #10 between 1018 on 12/14/17 until 1407 (nearly four hours). There were no nursing documentation on Patient #10 between 1407 and the time the patient arrived on the 4W general medical unit on 12/14/17 at 1751 (nearly four hours). Review of the ED Nursing documentation for Patient #10 revealed she was cared for by one female Patient Care Aide (PCA), Staff Y, one female Registered Nurse (RN), Staff GG, and one male nurse, Staff Z.

At this time, the list of concerned staff provided to the police was reviewed and revealed that Staff Y, Staff GG and Staff Z were not included. Further review revealed that no facility ED staff were on the list of staff who provided care to Patient #10 during her stay in the facility, despite an ED stay of approximately nine hours, with multiple hours of time with no documentation to indicate that Patient #10 was monitored or supervised.

Review of the facility policy entitled, "Patient Abuse, Adult", dated 06/2015, revealed the following statement, "All cases of suspected abuse, neglect or exploitation must be reported to the State of Michigan..." There was no documentation to indicate chain of command, reporting to Administration or police, investigation, documentation, protection, or reporting/.responding.

Review of the facility Policy entitled, "Event, Near Miss, and Sentinel Event Reporting", dated 10/19/17, revealed the following statements:

"We rely on comprehensive and timely reporting of all Events that do not meet policies and procedures as well as Near Misses, including the reporting of Sentinel Events. Those who are involved in, responsible for, or observe an Event or Sentinel Event must report them in compliance with this policy.'

"An Event is any happening or set of circumstances not consistent with the routine operation of the facility or routine care of a patient or visitor that reached the patient or visitor, regardless of whether it resulted in harm or injury."

"Sentinel Events include the following:...Sexual assault on a patient within or on the grounds of the healthcare facility"

"A root cause analysis and action plan must be completed upon discovery of an Adverse or Sentinel Event."
VIOLATION: PATIENT SAFETY Tag No: A0286
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the facility failed to document, track and analyze three medication errors and an adverse event for one (#10) of eight patients reviewed for medication errors and adverse events,out of a total sample of 17, resulting in the potential failure to detect and implement areas for quality improvement with the potential to impact all patients served by the facility.

On 2/22/18 at approximately 0900, review of the facility provided Adverse Event Report log, revealed only one adverse event was documented from 12/31/17 through 2/21/18, a patient fall.

On 2/22/18 at approximately 0910, review of the facility provided Medication Error and near Misses log from 11/1/17 through 2/21/18 revealed no documentation of a medication error for Patient #10.

On 2/22/18 at 1055 the facility Administrator/Medical Director, Staff I was interviewed regarding expectations for patient care and monitoring in the ED and reported that sometimes patients had to wait in the ED after admission for an inpatient bed to become available, but that they could and should receive the same care in the ED after admission that they would get if they were on an inpatient unit.

On 2/22/18 at approximately 1130, Patient #10's clinical record was reviewed and revealed the following:

A face sheet documented that Patient #10 was a [AGE] year old female who was transferred to the Emergency Department (ED) from a nursing home (SNF) on 12/14/17 at 0844 with a complaints of increased confusion.

An ED Physician's summary report dated 12/14/17 (no time indicated) documented that Patient #10 was bedbound and confused, and was diagnosed with [DIAGNOSES REDACTED]. The patient arrived on the 4W general medical unit on 12/14/17 at 1751

Review of Physician's Orders , and Medication Administration Records dated 12/14/17 revealed the following medications ordered by the physician in the ED were not given until the patient arrived in the inpatient unit at 1751, over seven hours later:

1. A loading dose of Vancomycin was ordered on [DATE] at 1128, and was not given until 1/14/18 at 1839.

2. A second antibiotic, Zosyn, was ordered on [DATE] at 1200 to be given every 6 hours, and an inpatient unit Nursing documentation on 12/14/17 at 2247 noted that the 1200 and 1800 doses were not given.

3. Pantoprazole (a medication to treat gastric reflux disease) was ordered on [DATE] at 1200. An inpatient unit Nursing entry on the Medication Administration Record dated 12/14/17 at 2247 noted that the ED 12/14/18 1200 dose was not given.

On 2/22/18 at approximately 1155, The Director of Nursing Practice, Staff L stated, "We talked to (Staff U) about the missing ED Nursing documentation. She broke down in tears."

On 2/22/18 at approximately 1200, The ED Manager, Staff U stated that care after admission should be the same in the ED as on an inpatient unit. When asked about Patient #10's missed doses of omeprazole and antibiotics, Staff U had no comment.

On 2/22/18 at approximately 1230, a second review of the facility's log of Medication Adverse Events and Near Misses revealed these errors were not included for review by the Pharmacy and Quality programs.
VIOLATION: NURSING SERVICES Tag No: A0385
Based on observation, interview and document review the facility failed to provide organized nursing services with sufficient numbers of nursing staff to follow the nursing process of identifying and responding to patient needs through assessment, care planning and documentation resulting in increased risk of unmet care needs for all patients. Findings include:

See specific Tags:

A 0392 - Adequate Nursing staffing to meet patient needs

A 0396 - Care planning not initiated upon admission

A 0405 - Medications not administered per policy and aceptable standards of practice
VIOLATION: STAFFING AND DELIVERY OF CARE Tag No: A0392
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based upon interview and document review, the facility failed to ensure the Emergency Department (ED) had adequate numbers of nursing staff to provide assessment and monitoring, nursing care and appropriate documentation of care per policy and standards of practice for five (#10, #11, #13, #14, #17) of seven patients reviewed for care in the Emergency Department out of a total sample of 17, resulting in the potential for missed care needs and less than optimal outcomes for all 205 patients in the ED. Findings include:

On 2/21/18 at approximately 1015 to 1100 a tour and observations of the ED was conducted with The ED director, Staff K and the ED Manager, Staff U, who were interviewed at that time.

On 2/21/18 at approximately 1015, the ED Registration Clerk, Staff P was interviewed and reported that incoming patients were seen immediately by the triage nurse, and if stable could wait in the waiting room to be seen by the physician. Staff P reported that a nurse took each waiting room patient's vitals every two hours and checked to make sure they were still stable.

On 2/21/18 at approximately 1020, the Ed Triage Nurse, Staff N was interviewed and reported that incoming patients were seen immediately by the triage nurse, and if stable could wait in the waiting room to be seen by the physician. Staff N reported that the triage nurse took each waiting room patient's vitals every two hours and checked to make sure they were still stable.

On 2/21/18 at approximately 1025, the ED Director, Staff K was asked about Nursing staffing in the ED and stated, "We try to have a staffing ratio of one nurse to four patients (1:4). We also have Patient Care Aides (PCAs) in addition to the nurses. If the volume of patients ramps up, we ramp up the staffing. Staffing needs are assessed twice a day, at 1100 and at 1500. The staffing matrix stays the same (baseline staff levels)." When asked at this time how staffing was adjusted to meet patient needs if large numbers of patients came to the Ed after 1500, Staff K said, " If we have too many patients waiting, the nurses can call the staffing office for additional staff from the float pool." Staff K reported that patients received an initial nursing assessment before they were seen by the Physician, and then had their vital signs (Temperature, Blood Pressure, Pulse, Respirations and Blood Oxygen Saturation) monitored and documented every two hours, even if they were waiting to be seen in the waiting room. Staff K stated that PCAs round in triage every two hours to do vital signs on all patients waiting to be seen.

On 2/21/18 at approximately 1030, ED Physician, Staff P was interviewed and stated that physicians checked the "online board" (Electronic Documentation System) frequently to monitor vital signs and nursing assessment on all patients in the ED or waiting to be seen after triage. Staff P stated that the protocol was that all patients needed to be checked by the nurse and have their vital signs taken at least every two hours in the ED.

On 2/21/18 at approximately 1035, ED Physician, Staff Q was interviewed and reported that for low priority (low acuity) patients, "there are days when they could sit for several hours." Staff Q reported that per protocol, nursing checked patients and recorded vital signs at least every two hours on all patients.

On 2/21/18 at approximately 1500 Patient #11's clinical record was reviewed with Staff L, and revealed Initial and regular Nursing assessments, monitoring and Care Plans were not documented as done in the ED:

Patient #11 was a [AGE] year old woman who arrived at the Ed by ambulance on 1/11/18 at 1220, with a diagnosis of [DIAGNOSES REDACTED]

An ED Physician's summary report dated 1/11/18 (no time indicated) documented that diagnoses included [DIAGNOSES REDACTED]

There was no initial ED Nursing Assessment or any additional ED nursing notes. There was no documentation to indicate that the nurse had monitored the patient's heart monitor for Patient #11. Additional documentation was requested but not provided by exit.

Patient #11's Vital Signs and assessments were documented at 1230 in triage, and at 1647 (six hours and 17 minutes later), at 1926, (two hours and 39 minutes later) and on 1/12/18 at 0106 (almost six hours later). There was no further documentation of vital signs or nursing assessment until the "Hand off Report" documented by the ED nurse on 1/12/18 at 0245. There were no additional nursing notes or assessments documented, despite the fact that the Physician noted continuous cardio-pulmonary monitoring as treatment plan. The facility was requested to provide additional documentation, but failed to do so by exit.

Review of ED Physician's orders revealed Patient #11 was admitted into the facility as an inpatient on 1/11/18 at 2242, and was transferred to an inpatient unit on 1/12/18 at 0330.

There was no Nursing Care Plan for Patient #11 initiated in the ED. There was no documentation of supervision for safety, or that Patient #11's nutritional, toileting, repositioning or other Activity of Daily Living (ADL) needs were assessed and met by ED staff during the 14 hours she was in the ED. The Hand Off Report documented that there was no family in attendance.

On 2/21/18 at approximately 1530, Patient #13's clinical record was reviewed with Staff L and revealed patient monitoring was not consistently documented as done per policy.

Patient #13 was a [AGE] year old male who (MDS) dated [DATE] at 1207 after a fall, and was triaged as ESI level 4 (stable) at 1217. Patient #13 was subsequently diagnosed with [DIAGNOSES REDACTED].

Review of Nursing documentation revealed an initial ED Nursing Assessment was documented as done at on 1/11/18 at 1545 ( three hours and 38 minutes after triage). ED vital signs monitoring and documentation was not done for nearly four hours between triage on 1/11/18 at 1218 and 1/11/18 at 1604 (3 hours and 46 minutes).

On 2/21/18 at approximately 1555, patient #14's clinical record was reviewed with Staff L and revealed the Initial Nursing Assessment was not done timely, there was no additional documentation of nursing care or monitoring, vital signs were not documented every two hours, and Nursing Care Plans were not initiated upon admission.

Patient #14 was a [AGE] year old female who (MDS) dated [DATE] at 1407 with complaints of right arm swelling and abdominal pain. Patient #14 was triaged at 1409 as an ESI level 3.

A Physician's ED Summary, dated 1/11/18, no time indicted, documented, "She was noted to be waiting for several hours before she was seen."

A handwritten, undated, untimed physician notation on Patient #14's Triage Report noted a history of [DIAGNOSES REDACTED] with [DIAGNOSES REDACTED], and right deep vein thrombosis (DVT). A Physician's ED Summary, dated 1/11/18, no time indicated, noted the patient was admitted to inpatient, with diagnoses including [DIAGNOSES REDACTED] with Metastasis, Severe Abdominal Pain, Acute Duodenitis, Abdominal Ascites, Large Right Pleural Effusion, and Rule Out DVT. Additional documentation was requested but not provided by exit.

The Initial ED Nursing Assessment was documented at on 1/11/18 at 2120 (over seven hours after the patient was triaged as level 3 Acuity.)

An order was written to admit Patient #14 to inpatient on 1/12/18 at 0027. There were no nursing care plans initiated after admission until the patient arrived on the inpatient unit at 0637.

Vital signs and nursing monitoring was documented on 1/11/18 at 1411(triage), 2109 (seven hours later), 2235, and on 1/12/18 at 0454 (six hours and 19 minutes later) and in the inpatient unit at 0637. There was no Hand Off Report or nursing documentation documenting when and how patient #14 was transferred to the inpatient unit, and no nursing documentation or monitoring documented for the seven hours between the time Patient #14 was triaged and the time documentation resumed.

On 2/22/18 at 0920, Patient #17's clinical record was reviewed with Staff L and revealed there was no documentation that Patient #17 was assessed by Nursing initially or subsequently, or received vital sign monitoring every two hours for the 17 hours and 55 minutes he was in the ED.

Patient #17 was an [AGE] year old male who arrived at the ED on 11/27/17 at 2130, referred by an Urgent Care Center for Generalized Weakness, Malaise and Hypotension. Patient #17 was triaged as ESI Acuity level 3 at 2133. A Physicians ED summary report dated 11/27/17 (no time indicated) revealed the patient was referred to the Ed from a nearby Urgent Care for a blood pressure of 64/40, elevated temperature, and generalized weakness and malaise.

Patient #17 was admitted for diagnoses of [DIAGNOSES REDACTED]

Patient #17 was transferred to the inpatient unit on 11/28/17 at 1530 ( 11 hours and 41 minutes after admission, and 17 hours and 30 minutes after triage.) There was no documentation of any nursing assessment done in the ED, or upon change of shift at 0700 on 11/28/17. There was no Nursing Care Plan initiated until Patient #17 arrived on the inpatient unit. There was no documentation to indicate that Patient #17's ADL care needs were assessed or met during his 17 hour and 30 minute stay in the ED. Vital signs were documented only twice during Patient #17's 17 hour and 30 minute ED stay, once at triage on 11/27/17 at 2135, and on 11/28/17 at 0347 (six hours and 12 minutes later).

On 2/22/18 at approximately 0950, The Patient Experience Supervisor (responsible for patient complaints), Staff S was interviewed regarding patient #17 and stated, "The family filed a complaint. It did look look like he was left in the ED. He was there waiting for a bed to be available in the inpatient unit. We talked with the ED manager about expectations for care in the ED. admitted patients who are waiting in the ED for an available bed in an inpatient unit should have a nurse assigned to them and care should be the same as if they were in an inpatient unit."

On 2/22/18 at approximately 1110, Patient #10's clinical record was reviewed with Staff L and revealed missing documentation of Nursing monitoring, vital signs were not monitored at least every two hours per policy, Medications were ordered and not given in the ED, and no Nursing Care plans were initiated in the ED after admission.

Patient #10 was a [AGE] year old female who (MDS) dated [DATE] at 0844 with a complaints of increased confusion. She was triaged timely at 0851 as ESI (emergency severity index) Acuity level 3 (level 1-2 are severe and must be seen and treated immediately, level 3 is urgent but not critical, level 4-5 are stable and are lower in priority and can be seen in an urgent care or "fast track area").

An ED Physician's summary report dated 12/14/17 (no time indicated) documented that the patient was bed bound and confused, and was diagnosed with [DIAGNOSES REDACTED]

The Nursing "Ambulatory Assessment History Report" documented that Patient #10's ED Nursing Assessment was started by Staff Nurse X on 12/14/17 at 0902, and completed by Staff Nurse Z at 1018.

There was an order to admit the patient to an inpatient unit, dated 12/14/17 at 1120.

There were no nursing documentation for Patient #10 between 1018 on 12/14/17 until 1407 (nearly four hours). There were no nursing documentation on Patient #10 between 1407 and the time the patient arrived on the 4W general medical unit on 12/14/17 at 1751 (nearly four hours). Review of flowsheets for Patient #10 revealed no documentation of patient monitoring, vital signs or assessments between 1018 to 1407 (nearly four hours), and between 1407 to 1751 (nearly four hours).

There was no nursing care plan initiated (in the ED) after Patient #10 was admitted to inpatient at 1120 until after the patient arrived on the inpatient unit at 1751. There was no documentation that Patient #10's dietary, repositioning or other Activity of Daily Living (ADL) needs were assessed and met by ED staff during the over eight hours she was in the ED. There was no documentation that Patient #10, a confused nursing home resident who was reportedly delirious (metabolic [DIAGNOSES REDACTED], high blood ammonia levels and UTI) was supervised for safety.

Medications ordered by the physician in the ED were not given until the patient arrived in the inpatient unit, over seven hours later. A loading dose of Vancomycin was ordered on [DATE] at 1128, and was not given until 1839. A second antibiotic, Zosyn, was ordered on [DATE] at 1200 to be given every 6 hours, and an inpatient unit Nursing documentation on 12/14/17 at 2247 noted that the 1200 and 1800 (while the patient was in the ED) doses were not given. Omeprazole (a medication to treat gastric reflux disease) was ordered on [DATE] at 1200. An inpatient unit Nursing documentation dated 12/14/17 at 2247 noted that the ED 1200 dose was not given.

On 2/22/18 at 1055 the facility Administrator/Medical Director, Staff I was interviewed regarding expectations for patient care and monitoring in the ED and stated, "It's a very valid complaint. I wouldn't want my loved one left in the ED like that." Staff I was unable to state what may have contributed to the deficiencies in ED nursing care for these five patients.

On 2/22/18 at approximately 1155, The Director of Nursing Practice, Staff L stated, "We talked to (Staff V) about the missing ED Nursing documentation. She broke down in tears. There was nothing to indicate that staff contacted the staffing office to ask for additional staff."

On 2/22/18 at approximately 1200, The ED Manager, Staff U stated that per policy, vital signs and documentation of nursing monitoring should be done at minimum every two hours in the ED, and each patient should have a nursing assessment done initially, and each shift. At this time, Staff K provided documentation of an agenda for an Ed Nursing staff counseling/training held on 2/21/17, "regarding the minimal ED requirement for documenting vital signs every two hours." Staff V was unable to explain why Nursing documentation on five of seven ED patients reviewed were missing documentation of nursing assessment, monitoring and provision of care if staffing levels were adequate.

In order to ensure that the deficient documentation was merely unavailable due to poorly interfacing EMRs (multiple paper and non-interfacing electronic record systems) the facility was requested to provide any additional documentation prior to exit, but when additional data was included, the above noted missing items were still missing.

On 2/22/18 at approximately 1210, Staff U and Staff M were requested to provide all ED Nursing policies. The Chief Nursing Officer, Staff M reported that there was no written facility policy on ED documentation, or on ED monitoring and assessment guidelines. At this time, the facility was requested to provide a policy on nursing assessment and monitoring, and a policy entitled, "Assessment of Patient", dated 12/2015 was provided that noted that a nursing assessment should be documented on admission, change of shift, or for a change in patient condition. There was no policy to provide guidelines on frequency of monitoring on any unit in the facility.
VIOLATION: NURSING CARE PLAN Tag No: A0396
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the facility failed to ensure that the nursing care planning process was documented as initiated and Nursing care needs were assessed on inpatient admission to the facility for four (#10, #11, #14, and #17) of five Patients reviewed for care in the Emergency Department (ED) after inpatient admission, resulting in the potential for less than optimal outcomes due to unidentified, unmet care needs for all four patients concerned. Findings include:

On 2/21/18 at approximately 1515 through 2/22/18 at 1700, clinical record review was done for five patients who remained in the Emergency Department (ED) for extended periods while waiting for an available bed in an inpatient unit after they were admitted as inpatients. Four of these five clinical records were from patients who waited in the ED for longer than four hours. None of these four patients who remained in the ED longer than four hours after inpatient admission had documentation to indicate that the nursing care planning process was initiated until after the patient arrived at the inpatient unit. There was no documentation to indicate that care needs for supervision, pressure injury prevention, or activities of daily living (toileting, food, and hygiene) were assessed or provided for during their stay in the ED, after or before inpatient admission.

On 2/21/18 at approximately 1500 Patient #11's clinical record was reviewed with Staff L, and revealed Nursing assessments, monitoring and Care Plans were not documented as done in the ED:

Patient #11 was a [AGE] year old woman who arrived at the Ed by ambulance on 1/11/18 at 1220, with a diagnosis of [DIAGNOSES REDACTED]

An ED Physician's summary report dated 1/11/18 (no time indicated) documented that diagnoses included [DIAGNOSES REDACTED]

Review of ED Physician's orders revealed Patient #11 was admitted into the facility as an inpatient on 1/11/18 at 2242, and was transferred to an inpatient unit on 1/12/18 at 0330 (4 hours and 48 minutes after admission and 15 hours after arrival in the ED).

There was no Nursing Care Plan for Patient #11 initiated in the ED. There was no documentation of supervision for safety, or that Patient #11's nutritional, toileting, repositioning or other Activity of Daily Living (ADL) needs were assessed and met by ED staff during the 14 hours she was in the ED. The Hand Off Report documented that there was no family in attendance. There was no Nursing care plan or interventions documented for cardiopulmonary monitoring.

On 2/21/18 at approximately 1555, Patient #14's clinical record was reviewed with Staff L and revealed the following:

Patient #14 was a [AGE] year old female who (MDS) dated [DATE] at 1407 with complaints of right arm swelling and abdominal pain. Patient #14 was triaged at 1409 as an ESI level 3.

A Physician's Ed Summary, dated 1/11/18, no time indicated, noted the patient was admitted to inpatient, with diagnoses including [DIAGNOSES REDACTED] with Metastasis, Severe Abdominal Pain, Acute Duodenitis, Abdominal Ascites, Large Right Pleural Effusion, and Rule Out DVT.

An order was written to admit Patient #14 to inpatient on 1/12/18 at 0027. There were no nursing care plans initiated after admission until the patient arrived on the inpatient unit at 0637 (six hours and 10 minutes after admission and 16 hours and 30 minutes after arrival in the ED). There was no documentation that Patient #11's nutritional, toileting, repositioning or other Activity of Daily Living (ADL) needs were assessed and met by ED staff during the 16 hours and 30 minutes she was in the ED.

On 2/22/18 at 0920, Patient #17's clinical record was reviewed with Staff L and revealed the following:

Patient #17 was an [AGE] year old male who arrived at the ED on 11/27/17 at 2130, referred by an Urgent Care Center for Generalized Weakness, Malaise and Hypotension. Patient #17 was triaged as ESI Acuity level 3 at 2133. A Physicians ED summary report dated 11/27/17 (no time indicated) revealed the patient was referred to the Ed from a nearby Urgent Care for a blood pressure of 64/40, elevated temperature, and generalized weakness and malaise.

Patient #17 was admitted for diagnoses of [DIAGNOSES REDACTED]

Patient #17 was transferred to the inpatient unit on 11/28/17 at 1530. There was no Nursing Care Plan initiated until Patient #17 arrived on the inpatient unit (11 hours and 41 minutes after admission, and 17 hours and 30 minutes after triage). There was no documentation to indicate that Patient #17's ADL care needs were assessed or met during his 17 hour and 30 minute stay in the ED.

On 2/22/18 at approximately 0950, The Patient Experience Supervisor (responsible for patient complaints), Staff S was interviewed 17 and stated, "We talked with the ED manager about expectations for care in the ED. admitted patients who are waiting in the ED for an available bed in an inpatient unit should have a nurse assigned to them and care should be the same as if they were in an inpatient unit."

On 2/22/18 at approximately 1110, Patient #10's clinical record was reviewed with Staff L and revealed the following:

Patient #10 was a [AGE] year old female who (MDS) dated [DATE] at 0844 with a complaints of increased confusion. She was triaged timely at 0851 as ESI (emergency severity index) Acuity level 3 (level 1-2 are severe and must be seen and treated immediately, level 3 is urgent but not critical, level 4-5 are stable and are lower in priority and can be seen in an urgent care or "fast track area").

An ED Physician's summary report dated 12/14/17 (no time indicated) documented that the patient was bedbound and confused, and was diagnosed with [DIAGNOSES REDACTED]

There was an order to admit the patient to an inpatient unit, dated 12/14/17 at 1120.

There was no nursing care plan initiated (in the ED) after Patient #10 was admitted to inpatient at 1120 until after the patient arrived on the inpatient unit at 1751 (8 hours and 31 minutes after admission and 11 hours and 7 minutes after she arrived in the ED). There was no documentation that Patient #10's supervision, dietary, repositioning or other Activity of Daily Living (ADL) needs were assessed and met by ED staff during the eight hours she was in the ED. There was no documentation that Patient #10, a confused nursing home resident who was reportedly delirious (metabolic [DIAGNOSES REDACTED], high blood ammonia levels and UTI) was supervised for safety.

On 2/22/18 at 1055 the facility Administrator/Medical Director, Staff I was interviewed regarding expectations for patient care and monitoring in the ED and stated, "It's a very valid complaint. Patients may have to stay in the Ed until a bed becomes available in one of the inpatient units sometimes. Care should be the same once a patient is admitted whether they are in a bed in the ED or a bed in an inpatient unit. I wouldn't want my loved one left in the ED like that." Staff I was unable to state what may have contributed to the deficiencies in ED nursing care for these five patients.

On 2/22/18 at approximately 1200, The ED Manager, Staff U was interviewed and stated that there were no written policies regarding standards of nursing care in the ED. Staff U stated that patients should receive the same nursing care in the ED after inpatient admission that they would get if they were in a bed on an inpatient unit. Staff V was unable to explain why four of five inpatient admitted ED patients reviewed were missing documentation that the nursing care planning process was begun and care needs and interventions assessed, planned and implemented in a timely manner after admission.

In order to ensure that the deficient documentation was merely unavailable due to poorly interfacing EMRs (multiple paper and non-interfacing electronic record systems) the facility was requested to provide any additional documentation prior to exit, but when additional data was included, the above noted missing items were still missing.

On 2/22/18 at approximately 1210, Staff u and Staff M were requested to provide all ED Nursing policies. The Chief Nursing Officer, Staff M reported that there was no written facility policy on ED documentation, or on ED Nursing Care of Patients after inpatient admission. A policy on Nursing Care Plans and documentation was requested, and review of the provided policies entitled, "Nursing Documentation", dated 10/09, and , "Nursing Process", failed to reveal statements to indicate what and when documentation of provision of ADL care and nursing interventions is required, or when the Nursing Care Planning Process should be initiated or completed, and interventions implemented.
VIOLATION: ADMINISTRATION OF DRUGS Tag No: A0405
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and document review, the facility failed to ensure that medications ordered by the physician were administered on time, per facility policy and standards of nursing practice, for one (#10) of five patients reviewed for care provided in the Emergency Department after inpatient admission, out of a total sample of 17, resulting in a delay in treatment and the potential for less than optimal treatment outcomes for the patient involved. Findings include:

On 2/22/18 at approximately 1110, Patient #10's clinical record was reviewed with Staff L and revealed three medication errors of omission occurred while she remained in the Emergency Department (ED) after admission, during her wait for an inpatient bed to become available.

Patient #10 was a [AGE] year old female who (MDS) dated [DATE] at 0844 and triaged at 0851.

An ED Physician's summary report dated 12/14/17 (no time indicated) documented that the Patient #10 was diagnosed with [DIAGNOSES REDACTED]

There was an order to admit the patient to an inpatient unit, dated 12/14/17 at 1120.

Review of the clinical record at this time revealed Patient #10 arrived on the inpatient unit at 1751 (six hours and 31 minutes after admission.

Medications ordered by the physician in the ED were not given until the patient arrived in the inpatient unit, over six hours later. The following missed doses were noted:

1. A loading dose of Vancomycin (an antibiotic) was ordered on [DATE] at 1128, and was not given until 1839 (7 hours and 11 minutes later).

2. A second antibiotic, Zosyn, was ordered on [DATE] at 1200 to be given every 6 hours. An inpatient unit Nursing Medication Administration Record documentation on 12/14/17 at 2247 noted that the 1200 and 1800 (while the patient was in the ED) doses were not given.

3. Omeprazole (a medication to treat gastric reflux disease) was ordered on [DATE] at 1200. An inpatient unit Nursing documentation dated 12/14/17 at 2247 noted that the ED 1200 dose was not given.

On 2/22/18 at 1055 the facility Administrator/Medical Director, Staff I was interviewed regarding expectations for patient care and monitoring in the ED and reported that sometimes patients had to wait in the ED after admission for an inpatient bed to become available, but that they could and should receive the same care in the ED after admission that they would get if they were on an inpatient unit.

On 2/22/18 at approximately 1155, The Director of Nursing Practice, Staff L stated, "We talked to (Staff U) about the missing ED Nursing documentation. She broke down in tears."

On 2/22/18 at approximately 1200, The ED Manager, Staff U stated that care after admission should be the same in the ED as on an inpatient unit. When asked about Patient #10's missed doses of omeprazole and antibiotics, Staff U had no comment.

In order to ensure that the deficient documentation was merely unavailable due to poorly interfacing EMRs (multiple paper and non-interfacing electronic record systems) the facility was requested to provide any additional documentation prior to exit, but when additional data was included, the above noted missing items were still missing.

Review of the facility policy entitled, "Medication Administration", dated 6/14/12, revealed the following statements:

"The Health Care Practitioner (HCP) will ensure adherence to the prescribed frequency and time of administration."

"Time critical medications must be administered within thirty (30) minutes before or after their scheduled dosing times for a total window of one (1) hour. The following medications will always be treated as time critical scheduled medications: Antibiotics."
VIOLATION: MEDICAL RECORD SERVICES Tag No: A0450
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on document review and interview, the facility failed to ensure that Emergency Department (ED) physician assessments were documented with the time performed for five (#10, #11, #13, #14, #17) of seven patients reviewed for care in the ED, out of a total sample of 17, resulting in the potential for inaccurate and incomplete clinical records, and potential failure to track and trend delays in care in the ED and identify areas for quality improvement, with a potential to affect all patients receiving care in the ED. Findings include:

On 2/21/18 at approximately 1020, the ED Triage Nurse, Staff N was interviewed and reported that incoming patients were seen immediately by the triage nurse, and if stable could wait in the waiting room to be seen by the physician.

On 2/21/18 at approximately 1035, ED Physician, Staff Q was interviewed and reported that for low priority (low acuity) patients, "there are days when they could sit for several hours."

On 2/21/18 at approximately 1500 Patient #11's clinical record was reviewed with Staff L, and revealed the following:

Patient #11 was a [AGE] year old woman who arrived at the Ed by ambulance on 1/11/18 at 1220, with a diagnosis of [DIAGNOSES REDACTED].

An ED Physician's summary report dated 1/11/18 (no time indicated) documented that diagnoses included [DIAGNOSES REDACTED]. Additional documentation was requested but not provided by exit.

On 2/21/18 at approximately 1530, Patient #13's clinical record was reviewed with Staff L and revealed the following:

Patient #13 was a [AGE] year old male who (MDS) dated [DATE] at 1207 after a fall, and was triaged as ESI level 4 (stable) at 1217. Patient #13 was subsequently diagnosed with [DIAGNOSES REDACTED].

On 2/21/18 at approximately 1555, patient #14's clinical record was reviewed with Staff L and revealed the following:

Patient #14 was a [AGE] year old female who (MDS) dated [DATE] at 1407 with complaints of right arm swelling and abdominal pain. Patient #14 was triaged at 1409 as an ESI level 3.

A Physician's Ed Summary, dated 1/11/18, no time indicted, documented, "She was noted to be waiting for several hours before she was seen." diagnoses included [DIAGNOSES REDACTED]#14 was initially seen by a Physician in the ED. The facility was requested to provide any additional documentation.

On 2/22/18 at 1300, a handwritten, undated, untimed physician notation on Patient #14's Triage Report was provided, and documented an initial assessment was done which noted a history of [DIAGNOSES REDACTED] with [DIAGNOSES REDACTED], and right deep vein thrombosis (DVT). Additional documentation was requested to indicate what time this assessment was done, but this was not provided by exit.

On 2/22/18 at 0920, Patient #17's clinical record was reviewed with Staff L and revealed the following:

Patient #17 was an [AGE] year old male who arrived at the ED on 11/27/17 at 2130, referred by an Urgent Care Center for Generalized Weakness, Malaise and Hypotension. Patient #17 was triaged as ESI Acuity level 3 at 2133. A Physicians ED summary report dated 11/27/17 (no time indicated) revealed the patient was referred to the Ed from a nearby Urgent Care for a blood pressure of 64/40, elevated temperature, and generalized weakness and malaise. There were no additional ED physician documentations, and no documentation to indicate the time the patient was initially seen by the physician. Additional documentation was requested but not provided by exit.

On 2/22/18 at approximately 1110, Patient #10's clinical record was reviewed with Staff L and revealed the following:

Patient #10 was a [AGE] year old female who (MDS) dated [DATE] at 0844 with a complaints of increased confusion. She was triaged at 0851 as ESI (emergency severity index) Acuity level 3.

An ED Physician's summary report dated 12/14/17 (no time indicated) documented that Patient #10 was bedbound and confused, and was diagnosed with [DIAGNOSES REDACTED]#10 was initially seen by a physician in the ED. Additional documentation was requested but not provided by exit.

On 2/22/18 at 1300 the Physician Director of Quality, Staff J was interviewed regarding documentation of the time of Physician assessments in the ED. Staff J stated that she did not believe that ED physicians were not consistently documenting the time of their initial and subsequent assessments and review of test results. Staff J stated that she was sure that this was being documented consistently, and stated that the problem may be due to lack of interface between electronic medical record (EMR) software systems.

In order to ensure that the deficient documentation was merely unavailable due to poorly interfacing EMRs (multiple paper and non-interfacing electronic record systems) the facility was requested to provide any additional documentation prior to exit, but when additional data was included, the above noted missing items were still missing.

A Policy on dating and timing of documentation was requested but not provided by exit.