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 interview, record review and a review of video, the facility failed to ensure that nursing care was fulfilled by authorized staff in accordance with the needs of a patient in a life threatening presentation which required consistent monitoring and accessible documentation in 1 of 9 sampled patients (#1).


Patient #1's medical record indicated that the patient arrived in the Emergency Department (ED) on 11/03/20 at 11:58 PM. The record stated that the patient's chief complaint was "Shortness of Breath/Dyspnea". Video which covered the ED lobby, looking from behind the desk of the Registrar, indicated that the patient's friend, who had brought the patient into the ED in a wheelchair, interacted with registration staff from 11:57:48 PM to 12:00:08 AM. At 12:00:08 AM on 11/04/20, the video showed the patient's friend taking the patient into the ED proper (which has access to the triage room). On 1/12/21 at 12:35 PM, registered nurse (RN) A stated that the Registrar had called her during the preceding timeframe. She stated that when she did, she sent the paramedic to get the patient while she started to set up a patient bed.

The facility had prepared a timeline of video they collected. It indicated that ED Paramedic A took the patient to the Triage room, from the ED entrance which opens into the lobby, at 11:59:45 PM. On 1/12/21 at 11:05 AM, the Director of ED stated the video could not be located. He confirmed what was documented.

Video from the ED lobby indicated that the patient was returned to the lobby in a wheelchair by her friend at 12:05:14 AM. This was approximately five minutes after she had been taken from the lobby. On 1/12/21 at 10:35 AM, Paramedic A stated that he had taken the patient to the Triage room. He stated that the patient's vital signs were taken and that they were on the upper range of normal. He stated that he did not enter them into the medical record. He stated that the patient exhibited difficulty in breathing. He stated that this was not entered into the medical record. He stated that, in his recollection, he reported the vital signs and his observations to the nurse after the patient was returned by him to the lobby. Paramedic A did not document patient information which could be used by others to accurately track the patient's overall status.

Per a review of video, the return to the lobby would have been at some point after 12:05:14 AM. However, per interview of RN A on 1/12/20 at 12:35 PM, she stated that she was not aware of the patient having been taken back to the lobby. Paramedic A stated that he believed that the best course of action was to wait for a nurse and that if he had the patient sent back to the lobby, the wait would not be too long. He confirmed that he did not stay with the patient once she was brought back in. On 1/12/20 at 12:35 PM, RN A stated that he asked for the patient to be brought to the hall bed and that Paramedic A complied.

Per the video timeline, it indicated that the patient was taken back into the ED proper by Paramedic A in a wheelchair at 12:07:26 AM. During an interview of the Director of ED on 1/12/21 at 2:21 PM, he confirmed what was documented.

Thus, a patient with a potentially life threatening condition had been left in the lobby setting, without any nursing or paramedic staff in a line of sight from 12:05:14 AM to 12:07:26 AM, period of approximately two minutes. This action placed a patient at risk for having a sudden, life threatening event in a setting without nursing or paramedic observation. In such a setting, timely intervention could not be effected if needed.

During an interview of the Director of Quality on 1/14/21 at 11:45 PM, she confirmed the findings.