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 SOUTHEAST TEXAS- ST ELIZABETH 2830 CALDER AVENUE BEAUMONT, TX 77702 Dec. 18, 2018
VIOLATION: PATIENT RIGHTS Tag No: A0115
Based on interview and record review the facility failed to:


A. ensure an adverse event that involved a patient death post transfer was fully investigated.

B. ensure an adverse event that involved a medication error for a 29-day old patient was fully investigated.


Refer to tag A144
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 patients received care in a safe setting for 2 (Patient #'s 18 and 20) of 2 sampled patients. The facility failed to ensure adverse events were completely and accurately investigated and preventative actions were implemented to prevent patient harm and medical errors.

This deficient practice had the likelihood to cause harm in all patients at the facility.


Review of incident/occurrence logs on December 19, 2018 revealed the following:


PATIENT #18

An incident was received on 8/15/2018. The event date was documented as 8/14/2018.

The incident report summary showed the following:

8/15/2018

Patient #18 was discharged from 2219. Staff #14 was RN. The patient was accepted by facility B without a DNR (Do Not Resuscitate) on file. EMS (Emergency Medical Services) took patient to facility B without an Out of Hospital DNR. When EMS arrived at facility B, the facility refused to accept the patient due to the patient's condition and no DNR. Facility B requested EMS for the patient be taken back to facility A. EMS took Patient #18 back to Intensive Care unit (ICU). The ICU staff told EMS they could not accept the patient back. They advised EMS to go through Emergency Department (ED) to have patient readmitted . The EMS left the ICU and went to the ED. The incident report documents that the EMS staff asked for a bed immediately. The EMS staff stated "The patient does not look good". The summary says the ED staff placed the patient on the ED tracker and assigned room 4B for Patient #18.


The complainant who wrote the incident report questioned and asked for investigation into inappropriate transfer in which patient #18 was inappropriately monitored, and that eventually caused patient #18's death.


The incident report showed the following referrals:

8/15/2018 - Referred to Staff #6 and Staff #7

8/17/2018 Staff #6 referred to Staff #15 and Staff #16.

8/27/2018 Staff #15 said the patient's condition at discharge had not changed from admission condition.

There was no follow up from Staff #16's referral.

There was a note documented from Staff #8 that EMS documentation had not been scanned in for review. The records were on downtime forms. The note said when the records were scanned in, they would be reviewed.


There was no additional investigation noted in the incident report.


Review of Patient #18's medical record revealed the following:

The facility document titled, "ER DOWNTIME FORM" revealed the following:

Staff #17 documented the following:

Signs/symptoms - "discharged from ICU. Now in resp failure per EMS and unresponsive. Refused by hospice, pt is a full code per D/C paperwork."

Procedures - "Intubation emergency for apnea, single attempt. CVC placement emergent for crash line - no access and severe hypotension"

Medical Decision Making Dx - "AMS, Hyperkalemia, Hypoxia"

Time of Death - 2:38 AM

The physician signature listed on the form was Staff #17.

Review of the facility document, "Trauma Nursing Assessment" revealed the following:
Staff # 18 documented the following notes:

Medications given:
10:04 PM - Atropine 1 mg IVP
10:08 PM - Epinephrine 0.5 mg IVP
10:09 PM - Ephedrine 10 mcg/min IV
10:12 PM - Epinephrine 1 mg IVP
10:23 PM - Levophed 30 mg/min IV
10:50 PM - Vasopressin 0.04 units/min IV
10:56 PM - D-50 2 amps IVP

Progress Notes

8/14/2018
9:55 PM - Patient arrived via EMS - No information on patient other than her name. Patient was just discharged from ICU 2219.

9:56 PM - Staff #17 called to bedside, extra nurses called to bedside, respiratory at bedside with Ambu-bag.

10:21 PM- patient intubated by staff #17.

10:45 PM - Patient went from Sinus Rhythm to asystole. CPR (Cardiac Pulmonary Resuscitation) started. ROSC (Return of Spontaneous circulation) was at 1047 PM


8/15/2018
1:45 AM - Sudden drop in heartrate. Staff #17 at bedside. Medicated. Loss of pulses, See code sheet #2.

1:50 AM - return of pulses. Family called at the same time. Staff #17 said to make the patient a full DNR. Verbal order from Staff #17 to stop all life sustaining drips. Change to DNR per family wishes.

2:38 AM Time of death by Staff #17


An interview with Staff #19 on 12-18-2018 at 2:10 confirmed that no investigation had been completed on the above incident.



PATIENT #20

An incident was received on 9/23/2018. The event date was documented as 9/23/2018.

The incident report summary showed the following:

9/21/2018
Twenty-nine (29) day old infant given Liquid Ibuprofen 49.55 mg for fever. There are no pediatric recommendations for infants less than six months old to be given this medication.


Referrals noted:

9/25/2018 Staff # 12 referred incident to Staff #6.

9/25/2018 Staff #12 referred to Staff #7.

9/26/2018 - Staff #6 documented that Patient #20 (MDS) dated [DATE]. Triage assessment at 1:24 PM reported that parents reported fever. Staff #20 entered CPOM (Computer Physician Order Management) order for Ibuprofen.

There was a notation in the incident report that documented - Defer to ED Leadership regarding follow up on possible inappropriate medication administration/order entry.

10/3/2018 Staff #8 reviewed records - Do not see any time in ED visit that the patient was febrile. The only remark of fever was stated by parent at triage. Staff #20 ordered Motrin and administered it at triage without a physician order. Staff #20 said Motrin was not given to patients below 6 months unless a physician ordered it.

10/11/2018 Staff #6 discussed with Staff #19 who stated she would follow up on incident with involved associate. There was no follow up documented.

There was no documentation of any further investigation.


Review of the medical record for Patient #20 revealed the following:

emergency room VISIT NOTES

9/21/2018

ER HPI
Initial Comments

This is a [AGE] year old brought by parents for chief complaint of subjective fevers yesterday of 104. Today the child was in the doctor's clinic at MD pediatrics was 100.2. Patient was seen by the Mid-Level provider and sent here for septic workup.

Arrival Vital Signs
9/21/2018 Temp 99.4 Pulse 188 Resp 50 Pulse Ox 100

Last Recorded Vital Signs
9/21/2018 98.9 Pulse 188 Resp 50 Pulse Ox 100

Procedures:
Lumbar Puncture 5:36 PM

Disposition:
admitted as IN- Patient 09



An interview on 12-18-2018 at 2:10 PM revealed the following:

Staff #19 said she was aware of the incident regarding Patient #20. Staff #19 said she had spoken with Staff #20 and re-educated Staff #20 on pediatric doses of Ibuprofen. Staff #20 was asked if she had any documentation of the conversation and Staff #20 confirmed she did not.


Review of the facility plan titled, "Patient Safety Plan" with a Fiscal year dated 2019 revealed the following:

" ...Quality, Risk Management and Guest Services Integration:

It is essential and part of this Quality Management Plan that the Quality Management and Management programs are integrated to assure the flow of information to the appropriate areas and to the department and committee level for review, action, and/or follow-up. Integration is accomplished through the following:

...Occurrence reports involving potential or actual quality issues are referred to and evaluated by the risk manager and patient safety committee."
VIOLATION: RN SUPERVISION OF NURSING CARE Tag No: A0395
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**




Based on interview and record review, the facility failed to ensure registered nurses provided an accurate evaluation and implemented interventions for patients who were at high fall risk in 2 (Patient #19 and Patient 21) of 2 patients reviewed. The facility scored 1 patient (Patient #19) at an inaccurate fall risk assessment that contributed to the patient falling at the facility. Also, the facility failed to implement interventions for 1 patient (Patient #21) that was high fall risk which contributed to the patient falling at the facility.

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


Findings include:


PATIENT #19


ED RECORD

Triage date time: 9/16/2018 3:03 PM by Staff #22.
Visit Information: [AGE] year old male. Patient #19 arrived to ED (Emergency Department) Via Stretcher. EMS (Emergency Medical Services) states seizure at house. Post ictal ( the altered state of consciousness after a seizure) upon arrival. New onset of seizures due to poor kidney function related to alcoholism. Patient is prescribed Keppra (Anticonvulsant), unsure if it is taken as prescribed. Family states seizure was 40 seconds long. Vital signs at triage - Blood pressure 98/52, Heart rate 105, Blood Glucose 105.

Pain Education: Patient is POST ICTAL

Fall Risk Screen Emergency Department:

Patient was scored at 35 (Moderate Fall Risk)

In the fall risk assessment Patient #18 was noted to be oriented.

According to the facility policy, "Fall prevention protocol" dated last reviewed/revision date of 1/2018, mental status shows that a patient who forgets limitations would be scored at 15 in mental status. If the patient was scored according to policy, the total score for Patient #19 would have been 50. A score of 50 would have placed patient in high risk score for Morse Fall Scores.

Patient Safety: Patient waking up post ictal

Neurological assessment: Patient arrived post ictal, extremely restless

ED General Reassessment - 9/16/2018 3:28 AM - Patient #19 is post ictal and extremely restless. Attempted to orient patient to surroundings, however unsuccessful.

ED Seizure Assessment - 9/16/2018 3:33 PM - Patient #19 is post ictal sleeping, confused, disoriented, restless, drowsy, arousable to deep pain.

MED/SURG Healing restraints - 9/16/2018 4:00 PM - Patient Behavior Agitation, pulling at Dressings, Climbing out of bed/chair. Placed in restraints - limb holder soft.

ED General Reassessment- 9/16/2018 4:17 PM - Patient #19 taken to CT (Computed Tomography) via stretcher for head and cervical spine CT.



Radiology Report:
Examination - Head or Brain without contrast, Cervical Spine without contrast
History - Fall
Impression- Negative non-contrast head CT, Negative non-contrast CT of cervical spine.


Medications Administered:
Lorazepam (Benzodiazepine used to treat anxiety), was given on 9/16/2018 at 3:15 PM IV
Keppra (Anticonvulsant), was given on 9/16/2018 at 4:13 PM




Review of the incident/occurrence report for Patient #19 revealed the following:

The event date was listed as 9/16/2018 at 3:55 PM. The incident was received on 9/16/2018.

The incident report summary showed the following:

Pt was post ictal from seizure - Pt calm sleeping - Nurse left patient in room to assist another patient. Nurse was called to the room by Respiratory Therapist Staff #23 who states, "Patient got on all fours and fell over bedrail."

Pt assisted back to bed and placed on monitor. Pt placed in restraints per Dr. Vartanina.

10/4/2018 7:39 AM the incident reported that discussion of patient falls was done at fall committee with nursing staff present.





PATIENT #21


ED RECORD

Triage date/time - 10/15/2018 3:42 AM by Staff #24. [AGE] year old male.

Chief complaint - Drug/ETOH complaint - Priority level assigned - 2

Vital signs at triage - Vital signs 10/15/2018 at 3:35 AM - Blood Pressure - 154/100, Pulse 124, Respiratory rate 16.

ASSESSMENTS

Adult Triage Assessment/Visit Information:
Reason for visit N/V loss of appetite. Left Sided body pain/tingle x 4-5 days. Patient #21 drank a pint of vodka today. Wants to be admitted for detox.

Psychiatric Reassessment
Patient oriented to person, place, date, situation. Mental Status - Pt has a history of alcoholism. Pt states "I'm trying to quit drinking on my own by cutting back. Pt reports only drinking a pint of vodka last night instead of 3.

Triage Assessment 10/15/2018 3:35 AM documented by Staff #24
Pt has tremors.

Adult Fall Screen
Pt was documented as High Fall Risk

ED GENERAL REASSESSMENT
Documented by Staff #25

10/16/2018 at 8:05 AM

Pt attempting to get out of bed, removing self from monitor, and hallucinating. Pt placed back on monitor. Pt reoriented. Staff #26 notified, orders received. No orders/interventions were noted to assign a sitter for Patient.

10/15/2018 8:35 AM
Pt found on floor in a sitting position. Multiple RN's at bedside. Pt states "I crawled over bed rails to get up ..."

10/15/ :43 AM
Pt. continues to try and get out of bed. Pt re-oriented and instructed to lay in bed ...curtains opened.

10/15/2018 9:43 AM
Pt admitted to room 2226.



MEDICATIONS ADMINISTERED

10/15/2018 4:48 AM- Lorazepam 1 mg (Benzodiazepine) given IV Push
10/15/2018 6:01 AM - Ativan 2 mg (Benzodiazepine) given IV Push
10/15/2018 6:15 AM - Phenergan 25 mg (Antihistamine) used to treat nausea given IV
10/15/2018 8:18 AM - Lorazepam 2 mg given IV Push - This medication was given 17 minutes prior to the patient being found on the floor.


Review of the incident/occurrence report for Patient #21 revealed the following:
Referral was done by Staff #12 to Staff #19 to have associate complete fall risk tabs. There was no response or follow up documented in the incident report.



An interview with Staff #19 on 12-18-2018 at 2:10 PM revealed the following:
Staff #19 said she was not aware of the above listed incidents.


Staff #19 confirmed the above finding.


Review of the facility policy titled, "Fall Prevention Officer" with a reviewed/Revised date of 1/2018 revealed the following:

" ...Fall Morse Scale (MFS): A rapid and simple method of assessing a patient's likelihood of falling. Widely used in acute care settings, both in the hospital and long term care inpatient settings.

V. PROCESS OR PROCEDURES
A. Procedure:
Acute care hospital and rehabilitation patients should also be screened for fall risk at least once per shift ...

a. Once a patient is determined to be a high risk for falls, the patient will be considered high fall risk for the remainder of their hospitalization and the focus of caregivers will be implementing fall prevention measures and the screening will shift to monitoring adherence with fall prevention measures.

b. Moderate fall risk interventions to reduce the risk of falls will be instituted for each patient determined to be at moderate or high fall risk and additional customized interventions will be implemented for high fall risk patients.

c.Each patient who falls will be appropriately managed and the fall will be investigated for possible environmental and patient specific changes ....

B. Responsibilities
.......5.Registered Nurse - Implements and oversees individually patient fall prevention care including:

a. Screening patients for fall risk on admission, transfer, change in condition, or following a fall using a valid/reliable assessment tool.

b. Screening patients each shift for fall risk.

c. Determining patient fall risk level and factors including risk, e.g. balance, cognition, anesthesia, age, and medication ....

e. establish appropriate patient plan of care with interventions specific to fall risk level. Based on additional risk factors, caregivers may increase the risk level for the patient to the next higher risk level to add additional measures to ensure patient safety. This additional precaution will be documented in the medical record ...."


Appendix C: Acute Care setting - Adult Fall Risk Screening Tool and Assessment

Morse Fall Scores
High Risk 45 and higher
Moderate Risk 25-44
Low Risk 0-24

Morse Fall Risk Screening Tool

Risk Factor Scale Score
History of Falls Yes 25
No 0

Secondary Diagnosis Yes 15
No 0

Ambulatory Aid Furniture 30
Crutches/Cane/Walker 15
None/Bed Rest/Wheel
Chair/Nurse 0

IV/Heparin Lock Yes 20
No 0

Gait Transferring Impaired 20
Weak 10
Normal/Bed Rest/Immobile 0

Mental Status Forgets Limitations 15
Oriented to Own Ability 0"
VIOLATION: EMERGENCY SERVICES Tag No: A1100
Based on observation, interview and record review, the facility failed to emergency needs were met using acceptable standards of care. The facility failed to:


A. ensure the Emergency department (ED) was organized in a manner to provide safe care. The facility failed to ensure 1 of 4 patients sampled on Cardizem drips (cardiac medication) received consistent and timely monitoring (Patient #2).

Refer to tag A1101 for additional information.


B. ensure adequate numbers of personnel to meet the needs anticipated by the facility in 1 of 1 Emergency department (ED).

The facility failed to ensure adequate number of Registered nurses (RN) and nurse technician's as per their staffing matrix and required needs during psych rotations.

The facility failed to ensure the staffing matrix was accurate and covered the increased volumes of patients that were being seen in the ED.

The facility failed to ensure Licensed vocational nurses (LVN) working in the ED received adequate supervision. The RN supervising an LVN was also responsible for her charge nurse duties and patient care on 8 patients.


The facility failed to ensure registration clerks and nurse technician performed duties within their qualifications.

Refer to tag A1112 for additional information.
VIOLATION: ORGANIZATION AND DIRECTION Tag No: A1101
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on interview and record review, the facility failed to ensure the Emergency department (ED) was organized in a manner to provide safe care. The facility failed to ensure 1 of 4 patients sampled on Cardizem drips (cardiac medication) received consistent and timely monitoring (Patient #2).

This deficient practice had the likelihood to cause harm to all patients who received cardiac drips in the ED.


Findings include:


Review of the clinical record on Patient #2 revealed she was a [AGE] year old female who (MDS) dated [DATE] at 9:01 a.m., with complaints of chest pain. Patient #2 was triaged at 9:07 a.m. and given an ESI level of 2 (meaning Semi- Emergent).

Review of the record revealed Patient #2 was medically screened by the physician at 9:04 a.m.. According to the clinical impression on the physician's screening revealed Patient #2 had a diagnosis of [DIAGNOSES REDACTED]

Review of physician orders dated 12/16/2018 revealed Patient #2 was placed on the cardiac drip Diltiazem/Cardizem 125 milligrams (25 milliliter) at 10 cc per hour.

The protocol on the order read as follows:

"Condition Dose/Route/Rate Instruction
Starting Rate 5MG/HR RANGE 0 TO 15 MG/HR
ADJUST EVERY 30 MINUTES 5 MG/HR WEAN TO MINIMUM REQUIRED
Text Keep HR 70-100 and SBP greater than 90"

Review of nursing documentation dated 12/16 2018 revealed the following:

At 10:42 a.m. vital signs were documented.

At 10:44 a.m., Patient #2 "started on a Cardizem infusion after 20 milligram bolus ...Patient is a fib on monitor with occ. pvc."

At 11:10 a.m., Patient #2's heart rate was 98 and she was on a Cardizem drip at 10 milligrams.

At 11:30 a.m., vital signs were documented.

At 12:04 p.m., Patient #2 was admitted to inpatient status.

At 1:00 p.m., Patient #2's Cardizem drip was infusing at 10 milligrams.

At 1:06 p.m. there was documentation of vital signs over 1.5 hours after the last vital sign.

At 2:04 p.m., vital signs were documented.

At 2:12 p.m., Patient #2 remained on a Cardizem drip.

At 4:03 p.m., there was documentation that Patient #2 remained on the Cardizem drip. There was documentation of vital signs at 4:03 p.m. (almost 2 hours after the last documented vital signs).

The stop time for the Cardizem was documented at 6:00 p.m. Vital signs were documented again at 6:14 p.m., after the completion of the medication and over 2 hours after the last documented vital signs.

At 8:06 p.m. (11 hours after presenting to the ED), Patient #2 was transported to the floor.


During an interview on 12/18/2018 after 9:00 a.m. Staff #7 confirmed the documentation in the chart.


During an interview on 12/18/2018 after 1:00 p.m., Staff #19 reported the nurses should be taking the vital signs every 15- 30 minutes.

Review of an undated ED policy named"CHRISTUS Hospital departmental Procedure" revealed the following:

Ultimately, the ED nurse should use his or her professional training and nursing experience to determine when to determine when to recheck the patient's condition and vital signs if no physician order exist for reassessment. In normal circumstances and with no physician order, the nurse may choose to initiate the following guidelines.

Category II- Initially and every 30-60 minutes as indicated by patient's condition.
VIOLATION: QUALIFIED EMERGENCY SERVICES PERSONNEL Tag No: A1112
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**



Based on observation, interview, and record review, the facility failed to ensure adequate numbers of personnel to meet the needs anticipated by the facility in 1 of 1 Emergency department (ED). The facility failed to:

A. ensure adequate number of Registered nurses (RN) and nurse technician's as per their staffing matrix and required needs during psych rotations.

B. ensure the staffing matrix was accurate and covered the increased volumes of patients that were being seen in the ED.

C. ensure Licensed vocational nurses (LVN) working in the ED received adequate supervision. The RN supervising an LVN was also responsible for her charge nurse duties and patient care on 8 patients.


D. ensure registration clerks and nurse technician performed duties within their qualifications.



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


Findings include:


ED FRONT ENTRANCE, TRIAGE AREA, AND MAIN ED AREA

During an observation on 12/17/2018 after 2:00 p.m., Staff #'s 9 and 27 were observed sitting at desk in the lobby areas of the front entrance. They were assisting patients get checked into the ED. Patients were sitting in both waiting areas up front, in chairs in the hallway outside of RMA area and in the RMA room.


The main ED area was observed to be full with patients. There were also patients in beds in the hallways.

Staff #26 (LVN) was observed in Room #5 in the main ED taking care of patients. Room #5 was a 6 bed room with a nurses station. Staff #25 (charge nurse) was out at the nurse's station talking to other staff and attending to other patient concerns in the ED.


Patient #29 was one of the patients in a hallway bed. Patient #29 had a nebulizer mask on and was receiving a breathing treatment. Patient #29 also had an oxygen nasal cannula on and the tubing attached was not attached to oxygen. It was underneath the bed and draped on the floor. Staff #8 stopped during the tour and took down one of Patient #29's intravenous bags which was empty.


Review of a clinical record on Patient #29 revealed he was a [AGE] year old male in with complaints of cough and congestion. Patient #29 presented at 8:18 a.m., and was triaged by Staff #25 (charge nurse) at 8:40 a.m.. Patient #29 was admitted at 11:54 a.m. and discharged from the ED to the floor as an inpatient at 3:01 p.m. (over 6 hours after presenting). Staff #25 documented providing care throughout the time Patient #29 was in the ED.


Staff #25 (charge nurse) could not supervise Staff #26 (LVN), be charge nurse for ED and provide care to other patients.




STAFF INTERVIEWS


During interviews on 12/17/2018 after 2:00 p.m., the following was stated about staffing in the ED;

"We are supposed to have 11 RN's, 2 NA's, and a ward clerk today. When we are holding patients to go upstairs we put them in the hallway. Sometimes we can call in extra people and sometimes we cannot. Today we are short."


Staffing in ED "rotten, two techs (NA) cannot run this ER" The NA's are not able to get everything done during their shift. They have to stock central carts, bedside care, linen, assist physicians, EKG, draw blood, vital signs, clean and reposition patients, transfer patients, and help bathe patients.

The techs are also responsible for linens, pumps, sterile carts and suture carts and retuning bedside commodes.


"We have been short of staffing. Today we do not have a tech in the back because she left sick and the charge nurse has multiple patients. She had patients in the hallway and is over the LVN. Today I have 5 patients. Room #6 (has 6 beds) is closed because we do not have enough nurses to open it. Room #5 has beds, but we can only use 4 of the beds today because the LVN is taking care of patients in there."

The charge nurse has 8 patients today. Supervising 4 with the LVN, 1 patient in Room #6 (which was supposed to be closed) and 3 in the hallway.

"Sometimes the charge nurses have to take 3-4 patients."


"No" there is not enough staff in the ED. "We are working at times with a total of 9 RNs, 1LVN and 1 tech. The patient hold times today are 24-27 hours and other times it has been up to 40 hours. The telemetry units are full and we have to hold patients until we can get a bed."


"Some days we have enough staff and some days we don't." Patients are put the tracker when they arrive and placed in the waiting area. We have to go out to the waiting area to triage them if it's full in RMA. The bed hold time lately is 24-27 hours. Sometimes chest pain patients are discharged from the ED and we still have to take care of them until they find a bed for them. We have a lot of traveler nurses, but they will not show up. There is an overall nurse staffing problem."


The techs are asking for the chief complaint when the patients arrive. Chest pain are supposed to go straight back to triage. If full they are placed in the waiting area and the nurses triages them in a one of the triage rooms near the waiting area. The tech does their EKG. When questioned about where in the record it would show where the techs were placing the chief complaint in the tracker. It was reported that the techs were placing the complaints in the wrong place in the computer. This was discovered last week and the only thing done was that it was written up.



"There had been a lot of changes in the lasts week for the registration process. There was a lot of misunderstanding on who was responsible for what jobs since the new process had started. The supervisor in registration had told her staff how the flow of the new throughput initiative was planned. The nurses in the ED (Emergency Department) had a different idea on what the registration clerks should do. One day last week a nurse came out to the registration desk and berated one of her co-workers for not doing her job."


"The registration clerks are put in a position to make clinical decisions at times. With the new process, the ED tech up front takes the patients complaint and made the decision on what type of patient went right back to the triage nurse. There was only one ED tech up front. If that ED tech was with another patient, the clerk was supposed to greet the patient walking in and put them on the tracker. The clerks were having to make the decision if the patients went back right away when they checked in the patient. There had been no communication with clerks from ED supervisor or administration in relation to the new process."


In the last two months the hold times had gone up a little from winter illnesses, but normally they do not. The throughput initiative had been developed to help move patients through the ED faster.


The new process seems faster, but still had a lot of kinks to work out. There are 4 Triage nurses but those nurses also care for the chair beds. If the patients in the chair beds have a lot of orders to complete then sometimes you would get a little behind on triaging.


"The ED needs more techs. The ED currently has one tech up front and one in the back. On busy days, that just isn't enough. If staff were holding patients in the ED for admission, then the tech in the back was tied up most of the shift. This was because most of the patients required assistance to get up and go to restroom, as the ED rooms do not have restrooms in them. When the tech was busy with helping those patients, it left the ED uncovered with a tech in the back to assist in transporting patients and assisting nurses with other patient care."





STAFFING NUMBERS


Review of a staffing matrix revealed numbers based on the following patient volumes: 124,125,131,132,134,138 and 143. There was no staffing numbers documented for volumes above 143.

During an interview on 12/18/2018 after 11:00 a.m., Staff #19 confirmed the volumes on the report and that they did not have staffing numbers on the matrix for volumes above the 143. Staff #19 reported the numbers on the matrix were based on an average for last year's volume in the ED.

Staff #19 reported they tried to always staff with 10 RNs and 2 techs/LVNs on non-psych weeks and 11 RN's and 3 techs/LVNs on psych week.


Review of staffing sheets from 12/06-17/2018 revealed the following:

On 12/06/2018 there was a patient volume of 124 and the matrix called for 10 RN's . This was also a psych week and the facility required one more extra RN.

The facility was short two nurses on days and nights.


On 12/07/2018 there was a patient volume of 140 and the closest number on the matrix to pull from was 138.
This was also a psych week and the facility required one more RN.

The facility was short two nurses on days and nights.


On 12/10/2018 there was a patient volume of 152 and there were no staffing numbers on the matrix for volumes above the 143. At 143 the matrix called for 10 RN's and 3 LVN/techs.

Review of staffing sheets revealed the facility was short by one nurse and one LVN/tech from 7a.m.-11:00 a.m. for 143 patients.

On 12/12/2018 there was a patient volume of 145 and the there were no staffing numbers on the matrix for volumes above the 143.

On 12/13/2018 there was a patient volume of 155 and there were no staffing numbers on the matrix for volumes above the 143. At a patient volume of 143 the matrix called for 10 RN's and 3 LVN/techs.

Review of staffing sheets revealed the facility was running 1- 2 RN's short on days and evenings for a volume of 143.


On 12/14/2018 there was a patient volume of 123 and the closest number to pull from was 124 on the matrix and it called for 10 RN's.


Review of staffing sheets revealed the facility was running 3 RN's short from 7:00 a.m.-9:00 a.m. and short 1 RN from 9:00 a.m.-11:00 a.m..


On 12/16/2018 there was a patient volume of 120 and the closest number to pull from was 124 on the matrix and it called for 10 RN's.

According to the psych rotation staffing level the facility was running 1 RN short from 7:00 a.m. -11:00 a.m..


On 12/17/2018 there was a patient volume of 132 and the matrix called for 10 RN's and up to 2 LVN/tech.

Review of staffing sheets revealed the facility was running 1 RN and 1 tech short on days.

According to the psych rotation staffing level the facility was running 2 RN's short.

During an observation on 12/17/2018 after 2:00 p.m., the LVN was observed with a patient load of 4. Therefore leaving one tech who was helping out in triage. There was no tech in the back to assist with patient care and the care of patients on hold.

During an interview on 12/18/2018 after 11:00 a.m., Staff #19 confirmed the staffing numbers.



Review of job descriptions of unit secretaries (7/2017) and patient care techs (6/2018) revealed no doccumentation of them having responsibilities to make clinical decisions involving triaging.


Review of the facility's policy named "Five-level Triage" dated 03/2017 revealed the following:

"..Triage is a rapid process that evaluates chief complaint, presenting symptoms, and assigns acuity level according to ESI Five Level Triage standards...

POLICY: A licensed professional nurse (RN), prior to financial registration, will assess every patient presenting to the Emergency Department requesting medical treatment or evaluation..."



Review of an undated ED policy named"CHRISTUS Hospital departmental Procedure" revealed the following:

"..Patients will receive safe care while in the ED environment....

..Patients should be transported to appropriate areas safely in a timely manner..."