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Based on observation, interview and record review, facility failed to meet the requirements of 42 CFR 482.1 as evidenced by failing to be primarily engaged in providing inpatient services.

Section 1861(e) of the Social Security Act defines hospital as: an institution that ". . . is primarily engaged in providing, by or under the supervision of physicians, to inpatients (A) diagnostic services and therapeutic services for medical diagnosis, treatment, and care of injured, disabled, or sick persons, or (B) rehabilitation services for the rehabilitation of injured, disabled, or sick persons..."

The facility failed to ensure a minimum average daily in-patient census of 2 patients over the last 12 months from November 1, 2023-October 31, 2024. The calculated in-patient average daily census was 1.06.

This deficient practice can affect all patients presenting to the facility for care.

Findings include:


During the entrance conference on 11/04/2024 at 1:05 PM, Staff #1 (Chief Nursing Officer and Administrator) of the facility stated they had two in-patients.

During an observation of the "inpatient unit" on 11/04/2024 after 2:00 p.m., Patient #2 was the only patient on the unit.

During an interview on 11/04/2024 at 3:00 p.m., Staff #1 (Chief Nursing Officer and Administrator) and Staff #2 confirmed that Patient #2 was the only in-patient on the unit. They also had Patient #3 who was an observation patient who left the facility at 11:21 a.m. on 11/04/2024.

Review of the "HOSPITAL/CAH DATABASE WORKSHEET" completed by Staff #1 (Chief Nursing Officer and Administrator) on 11/04/2024 revealed there was three offsite emergency departments and a total of four in-patient beds. Some of the services listed that were not provided in-house or through contracts were anesthesia services, intensive care, nursery, pediatrics, obstetrics, surgery services, occupational therapy, physical therapy services, psychiatric, social services, acute renal dialysis and speech pathology services.

Review of an unnamed facility report revealed from the months of November 2023-October 2024 the following total emergency room census:

Facility #1 (main campus) 11, 571 visits
Facility #2 (off-site) 6,704 visits
Facility #3 (offsite) 6527 visits
Facility #4 (offsite) 5679 visits


Review of a monthly inpatient report on 11/05/2024 at 9:51 a.m. revealed the following average in-patient daily census:

November 2023 - 1.70
December 2023- 1.81
January 2024- 1.77
February 2024- 1.72
March 2024- 1.13
April 2024- 1.03
May 2024- 0.81
June 2024- 1.83
July 2024- 1.00
August 2024- 0.97
September 2024- 1.33

The four inpatient bed capacity compared to the emergency room visits would not support emergency or unplanned admissions.

During an interview on 11/04/2024 after 4:00 p.m.., Facility #1 ED Staff # 13 (licensed vocational nurse) and Staff #5 (registered nurse) stated they transferred most of their patients out to Facility #5 and 6.

During an interview on 11/05/2024 at 9:51 a.m., Staff #1 (Chief Nursing Officer and Administrator) confirmed the numbers on the reports and stated that she receives the monthly report from the finance department. Staff #1 (Chief Nursing Officer and Administrator) confirmed the services they did not provde and stated that if the services were needed by an in-patient they would have to be transferred to another facility.

During an interview on 11/06/2024 after 8:33 a.m., Facility #2 ED Staff #15 (registered nurse) stated they transferred most of their patients out to Facility #5 and 6.


Review of the facility's unnamed reports of discharges, admission days, inpatient midnight census totals for the timeframe of November 1, 2023- October 31, 2024, revealed there was a total midnight census of 386 which calculated out to be an average daily census of 1.06.

During an interview on 11/05/2024 after 10:00 a.m., and 11/12/2024 at 10:48 a.m., Staff #1 (Chief Nursing Officer and Administrator) confirmed the accuracy of the numbers in the unnamed reports.

Based on record review and interview the hospital failed to ensure Emergency Services met the needs of 5 (Patients #1, #2, #3, #12, and #13) of 5 patients reviewed as exhibited by (AEB);


A. Three (3) of 5 (Patient #1, #2, and #3) patient medical records reviewed were assessed and reassessed for pain levels in the Emergency Department (ED).

B. Two (2) of 5 (Patients #12 and #13) patient medical records reviewed had vital signs assessed and documented every 2 hours and at time of discharge.

C. Two (2) of 2 Providers (Physician #17 and Nurse Practitioner #3) gave clear and direct orders on cleaning and irrigating wounds before nursing staff implemented treatments in 2 of 5 (Patients #1 and #13) patient medical records reviewed.

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


Refer to Tag A1101

Based on record review and interview the hospital failed to ensure Emergency Services were organized in a manner to provide complete and accurate patient assessments and complete physician orders as exhibited by (AEB);

A. Three (3) of 5 (Patient #1, #2, and #3) medical records reviewed were assessed and reassessed for pain levels in the Emergency Department (ED).

B. Two (2) of 5 (Patients #12 and #13) medical records reviewed had vital signs assessed and documented every 2 hours and at time of discharge.

C. Two (2) of 2 Providers (Physician #17 and Nurse Practitioner #3) gave clear and direct orders on cleaning and irrigating wounds before nursing staff implemented treatments in 2 of 5 (Patients #1 and #13) patient medical records reviewed.

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

Findings:

Patient #1

Patient #1 was a 31-year-old male who arrived at the hospital on 10/20/2024 at 1:21 PM with a chief complaint of a head laceration. He was transported to the hospital in a private vehicle.

Registered Nurse (RN) Staff #5 performed a focused triage assessment at 1:23 PM. There was documentation that the patient was hit in the head by a deer feeder and the patient's pain level was of 10/10. (The pain scale is a numeric scale ranging from 1-10 with 10 being the worst pain)". Blood Pressure- 147/113 (normal is 120/80), Temperature- 98.5 Fahrenheit, Heart Rate- 111 (normal adult heart rate is 60-100), Respirations- 18, Oxygen saturation of 96%, and Pain level of 10/10. (The pain scale is a numeric scale ranging from 1-10 with 10 being the worst pain)".

Physician #17 wrote an order for Norco 5-325 (pain medication) milligrams (MG) 1 tablet on 10/20/2024 at 1:36 PM. Norco 5-325 mg. It was administered orally at 1:43 PM by RN Staff #5.

RN Staff #5 documented a reassessment of the pain medication at 2:57 PM that read, "no reaction". RN Staff #5 failed to document a reassessment of the patient's pain score. This was 1 hour and 14 minutes after the medication was administered.

Physician #17 wrote orders on 10/04/204 at 1:36 PM to clean and irrigate the patient's wound. The order failed to give a specific solution to clean and irrigate the wound. Licensed Vocational Nurse (LVN) Staff #13 documented the wound was cleaned and irrigated at 2:12 PM but failed to document the solution used.

RN Staff #5 documented on 10/04/2024 at 2:56 PM the patient's Blood Pressure was 153/108, Heart Rate was 80, Respirations were 16, and oxygen saturation was 99%. There was no temperature or pain reassessment documented at this time.

A review of the discharge note dated 10/20/2024 at 2:57 PM by RN Staff #5 was as follows:

"Disposition:
Discharge: The patient was discharged with family. At discharge, the patient's status had improved. The patient was in good condition. The patient was considered stable. On a 0 to 10 pain scale, the patient's pain was unable to be determined ...The patient departed the facility on 10/20/2024 at 2:57 PM ..."


An interview was conducted with RN Staff #5 on 11/05/2024 at 2:30 PM. RN Staff #5 was asked after pain medication was administered, when was the pain level reassessed. RN Staff #5 stated, "It depends on how it was given." RN Staff #5 was asked if Patient #1's pain level was reassessed after the pain medication was administered or when the patient was discharged. RN Staff #5 stated, "Well, I didn't document it I guess". RN Staff #5 was asked if the physician was notified of the patients elevated blood pressure before he was discharged. RN Staff #5 replied, "No he was not but I think this patient's high blood pressure was from pain."

An interview was conducted on 11/05/2024 after 2:30 PM with RN Staff #5 and NP #3. RN Staff #3 was asked how did she know what solution to clean and irrigate the wound with if the physician failed to give a clear order. RN Staff #5 stated, "Well he told me to use saline". RN Staff #5 was asked if she placed a verbal order in the computer for clarification. RN Staff #5 stated, "No I did not but there is a drop-down item that allows them to add to the order for what they want. They can free text whatever they want in that area but they never do we just always use saline". NP #3 confirmed he was unaware that was an option for some orders.


Patient #12

Patient #12 was a 24-year-old female who presented to the ED on 11/03/2024 at 6:31 PM complaining of a tooth problem. A triage assessment was completed at 6:45 PM by RN Staff #19 and the vital signs were documented as a blood pressure of 139/70, pulse of 67, respirations of 18, temperature 98.1 degrees Fahrenheit, oxygen saturation 100% on room air and a pain level of 8/10.

The provider assessment was completed at 6:45 PM and orders were placed for Bicillin LA 1,200,000 units (an antibiotic) intramuscular (IM ) and Toradol (pain medication) 60 mg IM. The medication was administered by LVN #13 at 6:50 PM.

A review of the discharge disposition documented on 11/03/2024 at 6:55 PM by LVN #13 revealed Patient #12 was discharged 5 minutes after the administration of the IM medications. Further review revealed there were no vital signs documented at discharge. LVN Staff #13 documented the patient's pain level was a 5/10.

In an interview with the Director of Nurses (DON) Staff #2 on 11/05/2024 after 10:00 AM. DON Staff #2 confirmed there were no documented vital signs at discharge or if the patient had a reaction to the IM injection of the antibiotic administered by LVN #13.




Patient #13

Patient #13 was a 28-year-old male who arrived at the facility on 11/02/2024 at 11:07 AM with a head laceration. A triage assessment was completed at 11:09 AM by RN Staff #6. The vital signs were documented as a blood pressure of 151/98, a pulse of 92, respirations of 15, temperature of 98.2 degrees Fahrenheit, oxygen saturation of 96% on room air, and a pain level of 8/10.

The provider assessment was at 11:09 AM and NP #3 gave orders to cleanse and irrigate the wound at 12:18 PM. NP #3 failed to order a solution to cleanse and irrigate the wound. RN Staff #5 documented that the wound was "gently scrubbed" at 12:36 PM but failed to document the solution the wound was irrigated with. Also, NP #5 gave an order for Morphine (pain medication) 4mg IM. The morphine was administered by LVN Staff #13 on 11/02/2024 at 12:29 PM.

The next pain assessment was documented at 1:35 PM to be a 5/10. This was the same time the patient was discharged. There was no documentation of a vital signs reassessment at the time of discharge.

In an interview on 11/05/2024 after 11:00 AM, DON Staff #2 confirmed vital signs should have been assessed and documented at discharge.


A review of the facility policy titled, "Pain Management" P&P #: NUR.07 was as follows:

"PURPOSE: To assure that patients receive an assessment and management of their pain
consistent with the scope of care, treatment, and service provided by the
organization in its various care settings.

POLICY: Patients have the right to pain management. It is the policy of Altus Lumberton
Hospital to do the following:
1. Conduct an appropriate assessment and/or reassessment of a patient's pain consistent with
the scope of care, treatment, and service provided in the specific care setting in which the
patient is being managed.
2. Require that methods used to assess a patient's pain are consistent with the patient's age,
condition, and ability to understand
3. Assess the patient's response to care, treatment, and service implemented to address pain.
4. Treat the patient's pain or refer the patient for treatment ...

EMERGENCY DEPARTMENT

Routine Reassessment
If no pain issues were identified during the initial assessment, then no routine reassessment is
required. If acute pain issues were identified, then the patient should be reassessed at least at time of discharge or transfer. At a minimum, this reassessment shall consist of noting the intensity of the patient's pain ...

...Reassessment Following Treatment for Pain
If a treatment intervention for pain is provided, then the response to that intervention must be
assessed to include progress toward pain goal and side effects. Reassessment is recommended to occur within 15 - 60 minutes following treatment (depending on the type of intervention).
However, by policy, this reassessment must occur at least at the time of discharge or transfer ..."


A review of the facility policy titled, "Patient Assessment and Care Planning", P&P #: NUR.09 was as follows:

" ...POLICY:
This is an organization-wide document. As such, it applies to all settings in which patient care, treatment, and service are provided requiring the assessment of patient care needs.

ASSESSMENTS / REASSESSMENTS
Each clinical discipline shall define - in writing - the scope and content of
screening, assessment, and reassessment information that it collects. The depth and
frequency of collecting this information depends on the patient's needs; scope of
care, treatment, and service provided in a particular care setting; and the goals of a particular program or course of treatment. Information collection activities may vary between settings.
Information obtained during initial screens or assessments may indicate the need for further assessment or reassessment. At a minimum, the need for collecting this information shall be determined by the care, treatment, and services sought, the patient's presenting condition(s), and whether the patient agrees to the recommended care, treatment, or service ...

ATTACHMENT A
SUMMARY OF EACH DISCIPLINES SCOPE OF ASSESSMENT & REASSESSMENT ...

Nursing:
Assessment Time Frame
Emergency-Within 30 minutes of receipt into treatment area ...

Reassessment Time Frame
Minimum time frames are noted below:
Emergency Care
*Every two hours and upon transfer/discharge ..."





10135

Patient #2

Review of an Emergency department (ED) record on Patient #2 revealed he was a 57-year-old male who presented to the emergency room on 11/02/2024 at 5:27 a.m.. Patient #2 presented with complaints of back and flank pain.

Review of the record revealed the first set of vital signs were taken at 5:45 a.m. on 11/02/2024. Patient #2 had a blood pressure of 130/66, temperature of 99.8 degrees Fahrenheit, heart rate 100, respirations 17, oxygen saturation 95 percent and a pain level of 10/10 (meaning the worst level of pain).

A focused assessment was performed at 5:46 a.m. by Staff #18 (Registered nurse). There was documentation that Patient #2 had bilateral flank pain, pain radiating to bilateral feet, and a headache. There was documentation that the severity of the pain was severe and at an 8 (0-10 scale). There was no documentation in the record to indicate this was a medical screening and if it was deemed that Patient #2 had an emergency medical condition.

A physician's order was written on 11/02/2024 at 6:43 a.m. for the pain medication Morphine 4 milligrams intravenous push. It was administered at 7:00 a.m.. There was no documentation of an assessment of what the pain level was before or after the dose of Morphine.

Another physician's order was written on 11/02/2024 at 8:13 a.m. for the pain medication Morphine 4 milligrams intravenous push. It was administered at 8:33 a.m. There was no documentation of an assessment of what the pain level was before or after the dose of Morphine.

A physician's order was written to admit Patient #2 to inpatient status at 8:55 a.m. on 11/02/2024.

The next documented pain assessment was over 4 hours after the one taken at 5:46 a.m. Patient #2's pain level at 10:16 a.m. was at a severity level of 5 out of 10.

During an interview on 11/05/2024 at 12:00 p.m., Staff #1 (Chief Nursing officer/Administrator) stated that the assessment at 5:46 a.m. was the medical screening and that there was no documentation written to indicate it was or any notation of the existence of an emergency medical condition. Staff #1(Chief Nursing officer/Administrator) confirmed the lack of pain assessments on Patient #2.



Patient #3

Review of an ED record on Patient 3 revealed she was a 65-year-old female who presented to the emergency room on 11/03/2024 at 10:10 p.m.. Patient #3 presented with complaints of chest pain. The vital signs were documented as a blood pressure of 153/73, pulse 73, respirations 15, temperature 98.2 degrees Fahrenheit, oxygen saturation 97 percent on room air and a pain level of 5 out of 10.

The providers assessment was at 10:18 p.m., There was documentation that Patient #3 had complaints of chest pain that started 3 hours before presenting to the ED. The pain was sudden, unchanged since onset, intermittent, involved substernal area, aching and radiated to the left shoulder and arm. Patient #3 had moderate pain and had a history or coronary artery disease.

At 10:27 p.m., Patient #3 was administered a chewable aspirin 81 milligrams.

A set of vitals was taken again at 11:00 p.m., but there was no documentation of the pain level or if the aspirin was effective.

The next assessment of pain by nursing was over 6 hours later at 4:22 a.m. when the pain level was described as being 0 out of 10.

During an interview on 11/05/2024 after 12:00 p.m., Staff #1 (Chief Nursing officer/Administrator) confirmed the lack of pain assessments on Patient #3.

Review of a facility's policy titled "Pain Management "with an effective date of 12/09/2019 revealed the following:

"..EMERGENCY DEPARTMENT

...Routine Reassessment
If no pain issues were identified during the initial assessment, then no routine reassessment is required. If acute pain issues were identified, then the patient should be reassessed at least at time of discharge or transfer. At a minimum, this reassessment shall consist of noting the intensity of the patient's pain.
,,,Reassessment Following Treatment for Pain

If a treatment intervention for pain is provided, then the response to that intervention must be assessed to include progress toward pain goal and side effects. Reassessment is recommended to occur within 15-60 minutes following treatment (depending on the type of intervention). However, by policy, this reassessment must occur at least at the time of discharge or transfer ..."