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.

Based on observation, document review and interview, the facility failed to ensure that staff were provided access to handwashing sinks to enable staff to implement acceptable Standards of Infection Control Practices. This was evident in fourteen (14) of fourteen (14) Emergency Department (ED) Rooms observed.

The lack of handwashing sinks places all patients at risk for exposure to Infectious Diseases.


During a tour of the Emergency Department (ED) between 11:00AM and 12:30PM on 08/20/15, it was noted that fourteen (14) ED cubicles had two (2) beds in each cubicle. These cubicles were Fast Track Cubicles #1 and #2, and Main ED Cubicles #4-#7, #10-#14 and #18-#20.

It was also noted at the time of observation that the secondary beds were directly in front of the handwashing sink in each of the doubled cubicles, which would make the sinks inaccessible to staff for handwashing without moving the bed or leaning over the patient in front of the sink.

Further observation noted only one (1) shared sink in the Main ED outside of patient cubicles that was available for the ED staff to wash their hands. This sink was located behind the Nurses' Station across from the Soiled Utility and Clean Utility Room.

There was no available sink outside of the cubicles in the Fast Track Area.

This was confirmed with the Medical Director of the Department of Emergency Medicine, Staff #2, at the time of the observation.

During an interview with Staff Members #5 and #2 between 11:30AM and 12:30PM on 08/20/15, both stated that each of the ED cubicles were initially built for a single patient.

During an interview with Staff #8 on the afternoon of 08/21/15, in regard to the lack of handwashing sinks, the staff member stated that "this has been a concern since we first doubled the rooms years ago".

Based on record review and interview, the facility failed to ensure: a) that staff followed the facility's Policy for triaged patients that left without being seen by a Physician in one (1) of four (4) patients, and b) the development of a Policy to ensure that Emergency Department (ED) Registered Nurses (RN) receive periodic Training / Competency on CPI (Crisis Prevention Intervention) procedures.

Theses failures place all Emergency Department patients at risk for poor outcomes.


a) Review of the Medical Record for Patient J, a [AGE]-year-old female, documents that the patient (MDS) dated [DATE] at 4:32PM via car for Alcohol Intoxication with fall. At 7:40PM the patient was discharged to a friend.

Review of the Medical Record for Patient J, a [AGE]-year-old female, documents that the patient presented the next day to the ED on 06/19/15 at 7:44PM via ambulance for Alcohol Intoxication. As per the Ambulance Report "The patient was found sitting on the side of the road".

The Initial Triage was documented at 7:44PM. The MD was documented at bedside at 8:00PM. An MD Note at 8:10PM documents "Patient is not in the Treatment Room". An additional MD Note at 11:17PM documents "Patient left without being seen after triage".

Review of facility's Policy titled "Against Medical Advice" dated 06/2014 revealed on Page 4, under #8, "Elopement", that "The Nurse, MLP (Mid-Level Practitioners) or Physician responsible for the patient will attempt to contact the patient via telephone to ensure safety and encourage the patient to return to the hospital to complete care".

There was no documented evidence in the patient's Medical Record of a phone call to the patient.

In an interview on 08/21/15 at 11:40AM with Staff #2, the staff member stated "It is in our Policy, I am not sure why it wasn't done".

b) Interview on 08/21/15 at 11:30AM with Staff #6 (Director of Nursing Education) revealed that the facility did not currently have a Policy in place for periodic CPI Recertification of the ED RN staff. Staff #6 stated "I believe it [recertification] is in discussion ... they are currently talking about recertification for the existing staff".

On interview on 08/21/15 at 1:25PM, Staff #6 (Director of Nursing Education), stated "... it was decided that since the CPI course content had not changed or been updated, the focus is on the initial certification of the new ED RN employees, not recertification of the existing staff. There currently isn't a Policy for CPI recertification of the ED RN staff".

These findings were acknowledged and confirmed during interview on 08/21/15 at 3:30PM with Staff #1 (VP Quality, Patient Safety and Regulatory Affairs), Staff #6 (Director of Nursing Education) and Staff #9 (Assistant Director of Performance Improvement).

Review of the Personnel Files for the ED RNs (Staff Members #10, #11, #12, #13, #14, #15 and #16) lacked documentation of periodic CPI Recertification Training.

Staff #9 stated "The files do not have documentation of CPI recertification ... it isn't in there ... the ED RN staff are not recertified at this time".
Based on interview and document review, the Medical Staff failed to establish criteria delineating the qualifications a Medical Staff Member must possess in order to be granted Privileges for the supervision of the provision of Emergency Care Services.

This failure may lead to a non-qualified Medical Staff Member supervising the provision of Emergency Services.


Review of the facility's Medical Staff Bylaws, dated December 15, 2014, and the Emergency Department's Scope of Care, dated 2015, lacked written established criteria, such as necessary education, experience or specialized training, delineating the qualifications a Medical staff member must possess in order to be granted Privileges for the supervision of the provision of Emergency Care Services.

During interview on 08/20/15 at 2:04PM, Staff #1 (Vice President of Quality, Patient Safety, and Regulatory Affairs), stated " ... Physician Supervisors are informed, via email from the Medical Director, that they have been designated as charge ... this decision is based on their qualifications, skills and credentials, but I am not certain where that may be written".

During interview on 08/20/15 at 3:00PM, Staff #2 (Medical Director of Emergency Medicine), stated "There is no set criteria for Physicians supervising in the ED (Emergency Department) currently written in the Bylaws or the ED's Scope of Practice ... Physicians are credentialed through the hospital, Licensed, Board Certified, and trained with experience in the ED ... I thought being a Physician automatically qualifies you to supervise in the ED ... ".