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Based on interview and record review, the hospital failed to assign licensed nurses (LNs) to meet the needs of patients who presented to the Emergency Department (ED) for emergent care. ED patients were triaged (a medical process that involves sorting and prioritizing patients based on their medical needs and the available resources) then returned to the (ED) waiting room (WR), rather than be admitted to the main ED, due to practice of closing patient beds/rooms to free up a Registered Nurse (RN) to cover staff breaks.

This failure had the potential to result in delayed patient care and for ED patients to not receive ordered treatments and/or medications to address their emergent needs due to their placement in the WR where the patient's nurse cannot continually assess the patient's condition and obtain vital signs as the situation warrants and treatments are limited (e.g.: no IV, or IV medications may be given to the patient) to ensure the patient is not placed at risk for harm or injury while unattended by a RN in the WR.

Findings:

During a concurrent interview and record review on 9/17/24 at 9:17 a.m. of the 7/4/24 ED schedule with the ED Manager (EDM) and RNQ 3, the EDM stated she is "acting" or "interim" (there is no permanent manager currently) ED Manager, prior to this she was an ED Shift Manager. EDM stated she has taken over the staffing and scheduling for the ED. EDM explained her scheduling process, which includes staff self-schedule submissions, with the goal of an even number of staff assigned throughout the schedule (i.e.: high volume days are staffed with a greater number of staff to meet anticipated higher volume of patients coming to the ED for care). EDM stated her goal is to staff to a minimum of 10 RNs daily. EDM stated unanticipated leave of absences, sick calls and several open RN and ED Tech (ED Technician- main function is to support registered nurses in a hospital emergency department to provide the highest quality patient care.) positions have prompted her to submit four (4) "Traveler Requests" (nurses who are not employees of the hospital, but work for another agency and supply temporary help) to fill behind these open positions, however this process is not an immediate remedy due to the hiring and onboarding process can be approximately 4-6 weeks prior to being able to work in the ED. EDM stated that Central Staffing (department that manages the day-to-day staffing for patients admitted to the hospital) sometimes has staff available to float into the ED, as needed to supplement their nursing staff. EDM stated the nurse-to-patient ratio is 1 LN to 4 patients in the ED and they try to meet that requirement when scheduling LNs. EDM stated another goal is to staff a "break nurse" (a nurse whose primary job is to take over care for nurses so they can go on break). If a dedicated break nurse is not available, the nurses break each other (this means nurse A takes on nurse B's patient assignment (e.g.: nurse to patient ratio increases to 1:8 from 1:4) or the charge nurse covers breaks, or if trauma nurse (a registered nurse (RN) who specializes in providing life-saving care to patients with critical injuries or medical emergencies.) doesn't have patients in the trauma and higher acuity patient care areas (C and D pods) they can come over and help with breaks. EDM stated if a trauma patient presents for care, the trauma nurse must return to the trauma area to provide care. EDM stated "mid-shifters also help with covering breaks, as they arrive to work [at 9:00 a.m., 10:00 a.m., 11:00 a.m., 12:00 p.m., 3:00 p.m., and 3:00 a.m.] The EDM stated of the mid-shifters, "their assignments aren't fixed. There are days when staff do not get breaks, rarely happens." EDM stated D and C pods along with Express Care [of mental health patients] are always open. ED Tech assignments are based on area open in the ED, one ED Tech may be assigned to cover multiple areas such as in "B" pod- which is a "catch all area and doesn't always have an ED Tech assigned because aren't always open." EDM stated her expectation is that the ED Techs should be rounding, but it "doesn't always happen."

During a review of the facility P&P "Standard of Care Policy (ED.1.04) dated 10/23/22, the P&P indicated, " ...I. Purpose: These are the fundamental components of care that are to be applied to any patient presenting for treatment to the ED. This standard of care must be used in conjunction with more specific protocols that are relevant to the patient's chief complaint ...II. Policy: ...2. All patient conditions will be classified and prioritized utilizing the Emergency Severity Index [ESI] ...The patient's nurse is responsible for continually assessing the patient's condition and obtaining vital signs as the situation warrants . Patient acuity will determine the frequency of vital signs. Abnormal vital signs will be checked prior to discharge, and persistent abnormalities will be brought to the physician's attention ... 9 ....a. Documentation of any changes in patient status and physician notification when significant changes occur ..."

Based on interview and record review, the hospital failed to ensure physician telephone orders were authenticated (verified and signed) in patient's medical records within 48 hours in accordance with approved hospital policy and procedures for one of one patient (Pt 36).

This failure resulted in unverified physician orders and had the potential for inappropriate treatment and/or care of Pt 36.

Findings:

During a concurrent interview and record review on 9/12/24 at 10:43 a.m. with the Director of Women and Children Services (DWC), Pt 36's "History and Physical (H&P)," dated 9/6/24, was reviewed. The H&P indicated, " ...28 year old [gravida-the total number of confirmed pregnancies] 1 [para- the number of live births] 0 at 41.0 weeks gestation [the period of time when something is conceived and developed] presenting for scheduled induction of labor [IOL- when a medical professional uses medication or other methods to start labor before it begins on its own] ..."

During a concurrent interview and record review on 9/12/24 at 10:50 a.m. with the DWC, Pt 36's "Orders," dated 9/6/24 was reviewed. The Orders indicated, " ...OB Antepartum - Intrapartum ... Initiated and Electronically Signed by [Registered Nurse (RN) 7]-09/06/2024 [8:16 a.m.], Phone Read Back-Authentication ..." The DWC stated there was no physician signature for the telephone order received by RN 7. The DWC stated physician telephone orders required physician authentication within 48 hours.

During a concurrent interview and record review on 9/12/24 at 10:55 a.m. with the DWC, Pt 36's "Orders," dated 9/9/24 was reviewed. The Orders indicated, " ...Original order entered and electronically signed by [RN 8] on 09/09/2024 at [3:16 a.m.]. Phone Read Back-Authentication Required order by [MD] ... oxytocin [a synthetic hormone that helps speed up delivery or controls bleeding after childbirth] [intravenous] additive ..." The DWC stated there was no physician signature of the telephone order received by RN 8.

During a review of the facility's "Medical Staff Rules & Regulations," dated 4/29/21, page 12 indicated, " ...ORDERS ... All verbal orders for medications shall be authenticated, including the date and time of authentication, by the responsible or covering Practitioner within forty-eight (48) hours ..."

Based on observation, interview, and record review, the facility failed to maintain equipment in the kitchen to ensure an acceptable level of safety and quality when:

1a.The reach-in refrigerator # 27 was in need of a new gasket and was not holding the correct temperature,

1b. A small white home style refrigerator was not cooling.

1c. Reach-in refrigerator 16 had condensation dripping,

1d. Reach-in refrigerator 15 had a build-up of water on the bottom shelf.

1e. Metal shelves in two hot box warmers had coating that was peeling off.

1f. Deep fryer was not working and 3 of 6 convection ovens not working.

These failures had to potential to affect the food production and the facilities ability to provide safe and sanitary food to 231 medically compromised patients who received food from the kitchen.

Findings:

During an observation in the kitchen and concurrent interview with the Senior Director of Food and Nutrition on September 10, 2024 at 2:44 pm, reach-in refrigerator #27 was in need of a new rubber gasket for the door to seal properly. It was not maintaining a safe temperature for food storage. The SDFN 1 stated that because of the issue with the gasket they do not store food in the refrigerator just non-perishable sodas. SDFN 1 stated a worked order was placed on April 27, 2024.

During an observation in the kitchen on September 10, 2024, at 2:52 pm, a small white home style refrigerator was not working. The refrigerator was empty. In this same area there was 3 reach-in refrigerators, all three needed new gaskets. Refrigerator 15 had water collecting on the bottom shelf and refrigerator 16 had condensation dripping inside onto the food.

During an observation in the kitchen and concurrent interview with the Senior Director of Food and Nutrition on September 10, 2024, at 2:55 pm, there were two commercial food warmers with wire shelves. The coating on the shelves was peeling off. SDFN 1 stated the shelves needed to be replaced.

During an observation in the kitchen on September 10, 2024, at 3:11 pm, the deep fryer was not working.

During an observation in the kitchen on September 10, at 3:14 pm, 3 of 6 convection ovens were not working.

During an interview with the Director of Facilities (DOF 1) on September 11, 2024, at 9:40 am, DOF 1 stated he expects that equipment should be able to get fixed in a 30 day time frame, but usually that does not happen.

During an interview with the Registered Dietitian 1 (RD1) on September 12, 2024, at 2:40pm, RD1 stated that all equipment in the kitchen should be working and if something is not working there should be a work order put in and it should be fixed as soon as possible or 30 day or less.

During a review of the facility documents titled "Work Order Details", dated April 9, 2024, "top right oven is not working or coming to temperature.. On June 19, 2024, "bottom left oven of the ovens is not working". On June 21, 2024, "only 3 of 6 ovens working, please take a look at it since we use it on daily basis". On August 27, 2024, "oven is not working". On September 4, 2024, "left upper oven is not working".

During a review of the facility documents titled "Work Order Details", dated April 27, 2024, "gasket in 027 fridge needs to be changed. Old ones are torn up." On May 3, 2024, "2nd request gaskets on 2 of our fridges do not fit since being replaced this week, does not close completely". On June 21, 2024, "checking on the status of gasket for fridge #27".

During a review of the FDA Federal Food Code, dated 2022, 4-501.11 indicated, "(A) EQUIPMENT shall be maintained in a state of repair and condition ... (B) EQUIPMENT components such as doors, seals, hinges, fasteners, and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications." In addition, "Proper maintenance of equipment to manufacturer specifications helps ensure that it will continue to operate as designed. Failure to properly maintain equipment could lead to violations of the associated requirements of the Code that place the health of the consumer at risk."