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Based on record review and interview the facility failed to implement their Emergency Room (ER) Policy # ER 001 dated 1/2012 to ensure there was documentation that the chief complaints of patients in the Emergency Room are evaluated and assessed by a Registered Nurse during their ER stay and prior to discharge from the ER. Citing 4 of 5 patients #s 1,3,4, and 5.


Findings:

Patient # 1

Review of Emergency room triage notes for Patient # 1 revealed he was admitted to the emergency room on 10/18/2014 at 22: 32 with history of rectal bleeding that was getting progressively worst.

Review of Physician examination notes dated 10/18/2014 done by the Nurse Practitioner revealed he had a medical screen examination at 22:46. There was documentation the patient had rectal bleed which was grossly bloody, severe, all over the floor in the waiting room. Examination notes revealed he was bleeding frank blood from his rectum.
The medical diagnosis was gastrointestinal bleed and rectal bleeding. The medical plan was to transfer Patient ( #1) to the Intensive Care Unit for continued care and to be transfused with two units of blood.
Review of medication record revealed Patient #1 was given 2 mg of morphine at 22:35 there was no documentation the patient was assessed for the effectiveness of the medication. Patient #1 was in the Emergency Room for approximately four (4) hours. There was no documentation that the patient's bleeding and condition was assessed and evaluated by the nursing staff during his stay in the ER.


Patient # 3

Forty- nine years old admitted to the ER on 10/18/2014 at 22:52 with complaint he cannot eat, loosing weight, dizzy and having rectal bleeding.
His vital sigh was documented as follows:

Blood pressure 111/54, pulse 77, respiration 16, and temperature 98.1 degrees.

Physician history and physical dated 10/19/2014 at 11:00 pm revealed the patient is a chronic alcohol abuser. He had nausea and vomiting no abdominal pain. He was diagnosed with alcohol toxicity and the medical plan was for admission to inpatient unit for further observation and treatment. Patient # 3 left the ER on 10/19/2014 at 3:57 am for the unit. The patient spent approximately four (4) hours in the Emergency Room there was no documentation that the nurses evaluated and assessed the patient's condition after the initial nursing triage.


Patient #4

Twenty three year old patient presented to the ER on 1/13/2015 at 8:55 am with history of abdominal pain, nausea vomiting and diarrhea
Triage Nursing assessment was conducted at 9:06 am Temperature 98, pulse 54, respiration 18 and blood pressure 123/75.

Physician examination notes revealed the patient had abdominal pain, nausea vomiting and diarrhea which started nine (9) hours ago. Duration episodic with multiple episodes. the patient's abdomen was tender with mild guarding at the right lower quadrant. Blood cell count revealed elevated white count.

Diagnosis: gastroenteritis, appendicitis, food toxicity, bowel obstruction and dehydration.

Physician's notes on 1/13/2015 at 12:51 PM documented the patient's pain had decreased but was still having mild right lower quadrant pain and in light of the elevated white blood count admission for observation was decided. The patient was informed of the plans for care and refused to be admitted.

The patient was informed he might be having early appendicitis and diagnostic results were discussed. The patient left the facility on 1/13/2015 at 13:07. The patient was in the emergency room for 4 hours and was considered stable. There was no documentation by the nurse on his condition during the four hour stay. Vital sign were not re-checked prior to the patient leaving the hospital.

Patient # 5

thirty two ( 32) years old admitted to the ER on 1/14/2015 at 19:24 with early pregnancy having cramps since yesterday. Had previous history of hemorrhage during pregnancy.

vital sign: blood pressure 124/72, pulse 92, respiration 16. Patient also with history of cervical cancer and headache.

There was documentation the patient was evaluated by the physician and was diagnosed with Urinary Tract Infection in first trimester pregnancy. At 22: 19 the physician re-evaluated the patient's condition and determined her status had improved and she was for discharge.

Over the three hours the patient was in the ER there was one triage nursing entry at 19:27 when the patient arrived. There was no other documented evaluation of the patient by the nursing staff.

The patient was discharged on 1/14/2015 at 22: 56 with no evidence of a nursing assessment prior to discharge.

Review of the facility ' s Emergency Department Policy dated 1/2012 # ER 001 Title: Assessment of the Trauma Patient, documented the following information:

" Use the ENA( Emergency Nurses Association) /TNCC( Trauma Nursing Core Course) criteria to assist the nurse with the complete initial assessment of the trauma patient " . Included in the assessment is a requirement to:
" Assess the patient ' s chief complaint " .

Review of the facility's Department of Nursing Policy # PT-361dated 4/2014 titled Pain Management Guidelines section G:

"Reassessment is evaluation of the patient response to treatment and care in order to determine appropriatness and effectiveness of care decision."
Reassessment of pain is done at "suitable intervals after administration of medication( within one hour of parenteral or IM medications and within two hours of oral administration) or other intervention".

Review of the facility's Department of Nursing Policy # A-3 dated 12/2014 titled Assessment/Reassessment addressed the inpatient on the units and did not address nursing assessment/reassessment for patients in the Emergency Room.
During an interview on 1/15/2015 at 11:40 am with the Director of Quality she stated the assessment policies for the Emergency Department will be reviewed and documentation of nursing assessment of patients' condition while in the ER will also be evaluated for improvement.

Based on observation, interview and record review the facility failed to implement it's infection control policy # ICP 324 dated 1/2013 to ensure staff handle and store blood specimen in a manner to prevent cross contamination.
Failed to ensure housekeeping staff wear proper PPE (Personal Protective Equipment) when cleaning the facility to prevent the spread of infection. Citing random observations on two (2) of two(2) patient care areas.

Findings:

During observation in the Emergency Room(ER) waiting area on 1/14/2015 at 10:30 am housekeeping Staff (26) was observed wearing a pair of black heavy duty work gloves while he was performing housekeeping duties such as handling waste containers.
On 1/14/2015 at 11:10 am in the main ER Staff (#26)was observed cleaning with the same pair of heavy duty gloves on. The gloves were made from a grainy material that could harbor microbes and dirt.
During an interview on 1/14/2014 at 11:25 am with Staff (#26) he stated he wore the gloves for cleaning instead of the disposable gloves because it protects his hands from developing calluses. According to the Staff he cleans all areas in the facility which includes moping and using the buffer on the floor. He stated the disposable gloves do not provide sufficient cushion for his hands so he uses the heavy duty gloves. When asked how he sanitizes the gloves Staff (#26) stated the gloves were not cleanable.

During an interview on 1/14/2015 at 11:30 with Staff (#27) ER Manager she stated she did not notice the gloves until it was pointed out to her by the Surveyor she stated those gloves were not the correct PPE and in-services would be conducted with the staff.
Observation on the Intensive Care Unit (ICU) On 1/14/2015 at 9:30 am revealed two Registered Nurses collected blood specimen from patients at their bedside. Both Nurses wore disposable gloves during the collection of the blood. Both Nurses used their dirty gloved hands to place the tubes of blood in biohazard bags. They then took the bags in the same gloved hands and placed the bags on the Nursing station outside the patients ' room where clean supplies were stored and charting was done. After placing the bags with the blood specimens on the clean work area the nurses were observed handling the contaminated bags without gloves.
During an interview on 1/14/2015 at 9:55 am with Staff (#21) RN one of the two nurses that collected the blood specimen, she repeated the procedure of collecting and storing blood specimen as observed by the Surveyor. The Staff stated after verbalizing the process she realized the bags were contaminated and should not be placed in the clean area or handled without gloves.
Observation on the ICU on 1/14/2015 at 10:05 am revealed Staff (#28) Radiology Technician was cleaning the portable X-Ray equipment after completing a test in a patient ' s room. The Staff was holding the X-ray plate against his clothing during the cleaning process. He cleaned the entire portable x-ray equipment wearing one hand of glove, touching unclean areas of the equipment with his ungloved hands during the process. Staff (#28) removed the glove after cleaning and did not wash his hands.

Review of the facility's infection control policy # ICP 324 dated 1/2013 revealed the following information:
Specimen containers are considered contaminated and should be transported in a clear plastic "bag".
Review of the facility's infection control policy # ICP 324 dated 1/2013 revealed the following information:
"Remove gloves promptly after use, and wash hands immediately before touching non-contaminated items and environmental surfaces, and before going to another patient"
During an interview on 1/14/2015 at 10:10 am with Staff (#22)RN Manager of the ICU who was present for the observation she stated the Staffs would be re-educated on infection control measures.