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Based on review of the Chief Nursing Officer's job description, review of the Quality Assurance committee's meeting minutes, review of the facility's organizational chart, and interview, the facility failed to ensure Nursing Services was directed by a Chief Nursing Officer for 35 days (3/18/2020 - 4/21/2020) of 52 days reviewed during the period of 3/1/2020 until 4/21/2020 and failed to ensure a Registered Nurse (RN) was available to assess, supervise, and evaluate patient care for 1 Emergency Department (ED) patient (Patient #2) of 30 ED patients reviewed..

Refer to A-0386 and A-0393.

Based on review of the Chief Nursing Officer's job description, review of the Quality Assurance committee's meeting minutes, review of the facility's organizational chart, and interview, the facility failed to ensure Nursing Services was directed by a Chief Nursing Officer for 35 days (3/18/2020 - 4/21/2020) of 52 days reviewed during the period of 3/1/2020 until 4/21/2020.

The findings included:

Review of the Chief Nursing Officer's (CNO) job description, last revised 3/2018, showed "...The Director of Nursing [CNO] is responsible for planning, directing, controlling and evaluating the activities, functions, and personnel of all nursing units to ensure delivery of high quality patient care...Ensures appropriate staffing levels and mix to achieve and maintain effective nursing care...Ensures effective leadership in nurse managers to facilitate optimal quality of work life for staff...Direct the planning, development and implementation of staffing, capital and expense budgets...Prepare and forecast staffing plans..."

Review of the facility's Organizational Chart/Clinical Chain of Command dated 4/24/2017 showed "...clinical chain of command...[1] Chief Executive Officer [2] Chief Nursing Officer [3] Emergency Department Manager/Med Surg [Medical Surgical Unit] Manager..." Continued review showed the CNO was responsible for oversight of the following departments: Risk Management, Employee Health, Quality Assurance, Infection Control, Emergency Department, Medical-Surgical Unit, Pharmacy, Case Management, and the Respiratory Department.

Review of the facility's Quality Assurance Committee's meeting minutes for 3/2020 showed the CNO's last day of employment was 3/17/2020.

During an interview on 4/20/2020 at 2:30 PM, the ED Nurse Manager confirmed the CNO resigned on 3/17/2020 and the facility had not hired another CNO or appointed an interim CNO.

Based on review of facility policy, review of Emergency Department (ED) staffing schedules, review of employee time punches, review of facility documentation, review of the ED central log, medical record review, and interview, the facility failed to ensure a Registered Nurse (RN) was on duty 24 hours a day for 1 day (4/3/2020) of 52 days reviewed during the period of 3/1/2020 until 4/21/2020 and failed to ensure a RN was available to supervise patient care for 1 Emergency Department (ED) patient (Patient #2) of 30 ED patients reviewed.

The findings included:

Review of the facility's policy titled "TRIAGE" revised 5/2019 showed "...Patients presenting to the ED will be cared for according to a triage system utilizing an assessment by the ED personnel. This will be accomplished by using the Triage documentation on the ED record. The process will occur prior to seeing the ED provider...A brief history concerning medical problems, allergies and patient's chief complaint will be obtained..."

Review of the facility's policy titled "VITAL SIGNS" revised 5/2019 showed "...A complete set of vital signs will be taken on every patient age 6 years and older on admission..."

Review of the facility's policy titled "SCOPE OF SERVICES" revised 8/2019 showed services provided by the facility included "...Emergency Department...Staffed 24 hours a day, 7 days a week, 365 days a year (24/7/365) with a physician and a minimum of 2 licensed personnel (minimum of 1 registered nurse per shift)..."

Review of the facility's policy titled "Patient Diversion" revised 2/2020 showed "...When necessary because of a lack of capacity, capability to treat additional patients or equipment failure, diversion status may be initiated...Diversion...will be avoided if possible...Individual departments must continuously evaluate resources and patient demand and implement strategies for providing continued full-service to the community and minimizing diversion..."

Review of an ED staffing schedule dated 4/3/2020 showed no RN was scheduled to work in the ED from 7:00 PM until 8:00 PM. Continued review revealed the ED was staffed with a Physician and one Licensed Practical Nurse (LPN).

Review of the ED employees' time punches dated 4/3/2020 showed no RN was working in the ED from 7:00 PM until 8:50 PM (1 hour 50 minutes).

Review of a facility document dated 4/3/2020 showed the ED was on advisory (notification to Emergency Medical Services that the facility was not accepting patients) from 7:00 PM to 8:50 PM due to lack of a RN working in the ED.

Review of the ED Central Log dated 4/3/2020 at 7:00 PM showed 1 patient (Patient #2) presented to the ED for treatment during the time period of 7:00 PM until 8:50 PM.

Patient #2 presented to the ED on 4/3/2020 at 7:06 PM with a complaint of abdominal pain.

Review of an ED Physician's note dated 4/3/2020 at 7:06 PM showed Patient #2 complained of Abdominal Pain. Further review no documentation the physician obtained a medical history on Patient #2. ED Physician #1 performed a physical examination of the patient at 7:20 PM and noted the patient had mild, but worsening abdominal pain, nausea, abdominal distension, and dysuria (painful or difficult urination).

Medical record review showed no documentation a Nurse assessed or triaged Patient #2. Further review showed no documentation the patient's vital signs were obtained while she was in the ED and there was no documentation the patient received any interventions for pain. Continued review revealed no documentation diagnostic studies (laboratory studies or radiologic studies) were done to determine the cause of the patient's abdominal pain.

During an interview on 4/20/2020 at 2:30 PM the ED Nurse Manager stated an RN was not on duty on 4/3/2020 from 7:00 PM until 8:50 PM, resulting in Patient #2 not being assessed or evaluated by a RN.