Based on record review and interviews, the facility failed to ensure the nursing staff monitored, assessed and reassessed patients according to physician orders and the unit-specific policy. The failure was identified in 1 of 5 medical records reviewed (Patient #1). Findings include: Facility policy: The policy, Assessment/Reassessment read, the assessment framework will be structured around two components: initial screening/assessment and reassessment of all patients as appropriate to the clinical discipline and individual patient condition. Information generated via the patient's assessment/reassessment will be documented in the patient's electronic medical record (EMR). The reassessments are ongoing and occur at designated intervals during the patient's treatment to determine the response to and the effectiveness of care/interventions. According to the Clinical Assessment/Reassessment Guidelines, reassessments on the medical telemetry floor should be focused reassessments every shift, and as the patient's condition warrants. Documentation should occur within 2 hours. Performing an initial assessment included, but not limited to, physical assessments and vital signs. Reassessments were ongoing and triggered by pertinent data to include, but not limited to, acute change in the patient condition and/or change in diagnosis. 1. The facility failed to ensure the nursing staff conducted vital sign monitoring and physical assessments/reassessments according to the physician orders and the unit-specific policy. a. A record review was conducted for Patient #1 who was admitted as an inpatient on 8/26/19 due to complaints of abdominal pain, nausea/vomiting, and increased work of breathing. On the morning of 9/3/19, the patient was transferred to the intensive care unit (ICU) due to worsened clinical condition and physical decompensation. According to a physician order entered on 8/27/19 at 1:22 a.m., nurses were to notify the provider for the following vital signs: Temperature greater than 38.3 C, heart rate below 50, or a systolic blood pressure less than 90 Review of the medical record documentation from 9/1/19-9/3/19 found gaps in nursing physical assessments/reassessments and vital sign monitoring. The review also found a lack of evidence the provider was notified of changes in the patient's condition per the 8/27/19 order. i. For example, on 9/1/19 there was no documented evidence the patient's primary day shift nurse conducted and documented a head to toe assessment during the shift. The lack of assessment was non-compliant to the unit-based policy which stated assessments should occur at least once a shift. ii. On 9/2/19 at 12:43 p.m., documentation of Patient #1's vital signs found abnormal results with no timely reassessment of vitals or physician notification as needed. Patient #1's blood pressure was documented by a registered nurse (RN #1) as 84/54 with a heart rate of 32, both critically low. According to the record, the patient's vital signs weren't rechecked until 9/2/19 at 4:18 p.m., three and a half hours later. Though the blood pressure and heart rate were found to be within normal limits, the patient's temperature was 38.4 C and indicated the presence of a fever. However, there was no documented evidence the primary nurse reassessed, treated, or notified the provider of the abnormal vital sign value in a timely manner. iii. Further review of Patient #1's medical record identified another gap in the patient's head to toe assessment. On 9/3/19 at 12:20 a.m., the nurse reported to the physician that Patient #1's medical condition had worsened and requested the patient be transferred to the ICU for closer monitoring. Review of the nurse's documentation found no evidence of a documented head to toe assessment during their shift. Therefore, the record review was unable to identify the patient's baseline physical assessment at the start of that shift. b. On 2/19/20 at 11:43 a.m., an interview was conducted with RN #1. RN #1 stated the medical surgical (med/surg) nursing staff were expected to conduct a head to toe assessment at the beginning of their shift to establish the patient's baseline medical status. RN #1 stated a reassessment was warranted if the patient experienced a change in medical condition. RN #1 stated vital signs should also be reassessed if an abnormal finding was identified. RN #1 stated all assessments/reassessments, interventions, or notifications to the physician regarding the patient's change in clinical condition must be documented in the medical record. c. On 2/20/20 at 1:09 p.m., an interview was conducted with RN #2 who was staffed on the med/surg unit as a charge nurse. According to the interview, the certified nursing assistants (CNA) typically collected patient vital signs on the med/surg unit, but the charge nurses could assist as needed. RN #2 stated vital signs were collected on a mobile machine and electronically transferred to the patient's EMR. If an abnormal vital sign was found, they should be immediately reported to the patient's primary nurse. RN #2 stated this was important because the primary nurse was responsible for knowing the patient's vital signs, determining if normal or abnormal, and ensuring the vital signs were documented in the EMR. i. RN #2 reviewed the medical record for Patient #1 and confirmed she had collected Patient #1's vital signs on 9/2/19 at 12:43 p.m. RN #2 confirmed the vital signs were abnormal, and if accurate, required immediate medical intervention. RN #2 stated she could not remember the patient, and the documentation may not be accurate, but it was the responsibility of nursing staff to ensure accurate vitals were documented in the medical record. RN #2 stated the documented vital signs would require an immediate reassessment of the patient and vital signs, notification to the primary nurse, and treatment or notification to the physician if the patient was symptomatic. RN #2 stated if the patient had an irregular cardiac rhythm, or issues with the pulse oximeter (a non-invasive device that measured the oxygen saturation of a person's blood as well as their heart rate) cord on the patient's finger, an inaccurate heart rate value could have been recorded in the EMR. However, she reinforced it was ultimately the responsibility of the nurse to assess and reassess patients as needed, and ensure the accuracy of nursing assessments/reassessments recorded in the EMR. d. On 2/24/20 at 10:00 a.m., an interview was conducted with the med/surg unit manager (Manager #3). Manager #3 stated nurses were expected to obtain vital signs and physical assessments/reassessments according to the unit's policy and the physician orders. Manager #3 reviewed the record for Patient #1 and confirmed the gaps in nursing physical assessments and vital sign reassessments. Manager #3 stated abnormal physical findings and vital signs must be reassessed and treated, or the physician notified as needed. Manager #3 stated the facility had not previously identified this concern, or conducted any process improvement activities to address gaps in nursing vital sign monitoring or physical assessments/reassessments.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in º489.24, related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. Findings: 1. The facility failed to meet the following requirements under the EMTALA regulation: Tag A2405 - emergency room Log - The facility failed to ensure that a central log was accurately maintained to include all patients seeking emergency care at the facility and to reflect the correct disposition of patients seen in the Emergency Department (ED). Specifically, one patient who (MDS) dated [DATE], with a complaint of chest pain was not entered on the central log (Patient A) and the disposition listed on the log was incorrect for 4 of 20 patients reviewed (Patients #3, #15, #19, and #20). Tag A2406 - Medical Screening Exam - The facility failed to ensure a Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel (QMP) in 1 of 2 records reviewed for patients who presented to the facility for an emergency evaluation during a time when the facility was in lockdown (Patient A). This failure resulted in the delay of care for a patient experiencing an emergency medical condition.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on review of facility documents and staff interviews the facility failed to ensure that a central log was accurately maintained to include all patients seeking emergency care at the facility and to reflect the correct disposition of patients seen in the Emergency Department (ED). Specifically, one patient who (MDS) dated [DATE], with a complaint of chest pain was not entered on the central log (Patient A) and the disposition listed on the log was incorrect for 4 of 20 patients reviewed (Patients #3, #15, #19, and #20). FINDINGS: POLICY According to the EMTALA (Emergency Medical Treatment & Active Labor Act) Central Log Policy, the hospital will maintain a Central Log containing information on each individual who comes on the hospital campus requesting assistance or whose appearance or behavior would cause a prudent layperson observer to believe the individual needed examination or treatment, whether he or she left before a medical screening examination could be performed, whether he or she refused treatment, whether he or she was refused treatment or whether he or she was transferred, admitted and treated, stabilized and transferred or discharged . The procedure section of the policy read, A log entry for all individuals who have come to the hospital seeking medical attention or who appear to need medical attention must be made by the appropriate individual. 1. The facility failed to maintain a complete and accurate central log of patients who presented to the facility. a) Review of an internal management report, entered at 3:28 p.m. on 3/23/18, showed an individual came to the emergency department (ED) on 3/22/18 with chest pain. The report indicated the patient spoke with a security officer at the ED and then left the ED and sought care at another acute care hospital. The report noted that a risk manager at the acute care hospital, that subsequently treated the patient on 3/22/18, called and reported the patient said the security officer told him the hospital couldn't admit anyone because of the lockdown that was in place. Review of the electronic Central EMTALA Log for 3/22/18 revealed no entry for Patient A. During an interview with the Director of Emergency Services, Adult Emergency Department (Director #2), on 5/2/18 at 9:00 a.m., Director #2 stated individuals who came to the ED but decided not to be seen would still be entered into the EMTALA log using an identification number issued by patient access. According to Director #2, the sex and approximate age of the individual was entered and left prior to triage was entered as the disposition type. Regarding the occurrence from 3/22/18, Director #2 stated we didn't think about it but we should have gone back and entered that patient onto the log. b) Patient #3 (MDS) dated [DATE] at 5:48 p.m. with complaints of right side head pain and vision changes. Review of the medical record indicated that after an examination had been conducted the practitioner discussed the risks and benefits of further diagnostic testing and specific procedures. Patient #3 was unsure how he wanted to proceed and asked to think about next steps. When the practitioner returned to the room at 6:55 p.m., Patient #3 had eloped from the emergency department. Review of the EMTALA log for 4/1/18 listed the Disposition Category for Patient #3 as refused treatment and the Disposition Type as against medical advice. c) Patient #15, a [AGE] year old male, (MDS) dated [DATE] at 12:29 p.m. with complaints of worsening abdominal pain, vomiting and diarrhea. Review of Patient #15's medical record indicated the patient was being seen by a vascular surgeon at a different acute care hospital for a complex medical condition. After consultation with Patient #15 and the vascular surgeon at the different acute care hospital, it was decided to transfer Patient #15 to that hospital for continuity of care. Review of the EMTALA log for 4/17/18 listed the Disposition Type for Patient #15 as transferred to a critical access hospital. d) Patient #19, a [AGE] year old male, (MDS) dated [DATE] at 1:28 a.m. with complaints of abdominal pain. Review of the medical record indicated Patient #19 required surgery and he was transferred to the care of a pediatric surgeon at a different acute care hospital. However, review of the EMTALA log for 4/4/18 listed the Disposition Type for pediatric Patient #19 as transferred to a critical access hospital. e) Patient #20, a 5 year old female, (MDS) dated [DATE] at 4:40 p.m. with a sore throat and ear pain. Review of the medical record indicated Patient #20 was treated and discharged home in the care of her mother with instructions to follow up with the child's primary care physician. However, review of the EMTALA Log for 4/4/18 listed the Disposition Place for pediatric Patient #20 as jail. f) Director #2, was asked during the 5/2/18 interview who reviewed the EMTALA log for accuracy. Director #2 stated she reviewed the log for the adult emergency department daily. She would review the log in comparison to the patient's medical record to ensure accuracy. Director #2 stated she would review the medical record to ensure the treating practitioner entered the correct disposition category on the log and that the nurse entered the correct disposition type and place. When asked about the log discrepancies noted for Patient's #3, #15, #19 and #20, Director #2 stated that the electronic health record (EHR) software allowed for a limited number of disposition types and that sometimes the correct disposition type was not an option to select in the system. Director #2 stated when I started here as the manager I brought up the discrepancy regarding [the EHR] and was told that it was a glitch in the software and to be honest I have not pursued the issue again.
Based on interviews and document review, the facility failed to ensure a Medical Screening Exam (MSE) as required by Emergency Medical Treatment and Labor Act (EMTALA) regulation was provided by qualified medical personnel (QMP) in 1 of 2 records reviewed for patients who presented to the facility for an emergency evaluation during a time when the facility was in lockdown (Patient A). This failure resulted in the delay of care for a patient experiencing an emergency medical condition. Findings include: Facility policy: According to EMTALA Medical Screening Examination and Stabilization Policy, an EMTALA obligation is triggered when an individual comes to a dedicated emergency department (DED) and requests an examination or treatment for a medical condition. The hospital must provide an appropriate MSE within the capability of the hospital's emergency department (ED) to determine whether or not an EMC exists. The hospital must perform an MSE to determine if an EMC exists. It is not appropriate to merely log in or triage an individual with a medical condition and not provide an MSE. Triage is not equivalent to an MSE. 1. The facility failed to ensure all patients who presented to the facility seeking emergency medical treatment received a medical screening examination (MSE) to determine if an emergency medical condition existed. a) Review of an internal management report, dated 3/23/18 at 3:28 p.m., revealed Patient A presented to the emergency department (ED) on 3/22/18 with a complaint of chest pain. According to the report a security officer greeted the patient as the ED was in a security lockdown status. During an interview, on 5/2/18 at 11:20 a.m., with Hospital Security (HS) #3, he stated he was the person who greeted Patient A when the patient arrived at the ED on 3/22/18. HS #3 stated his roll on 3/22/18 was to bring patients and visitors into the ED and check bags. HS #3 stated the ED was very busy that day and there were a bunch of patients and visitors sitting in the lobby. He stated Patient A came into the ED and told him he was having chest pain and wanted to be seen. HS #3 said the patient asked how long it would take and he told the patient he didn't know how long it would take but they would put the patient at the head of the line and get him seen as soon as possible. HS #3 stated he pointed to where the emergency medical technician (EMT, the employee who completed the triage) was sitting and told Patient A he would be next in line. HS #3 stated he didn't know why the EMT did not come over to where the patient was and stated he did not request the EMT to come over. HS #3 stated Patient A kept asking how long is it going to be and HS #3 told the patient he couldn't give him an exact time but told the patient he could see the EMT. During a tour of the ED, on 4/30/18 beginning at 11:50 a.m., Lead Security Officer #4 (LSO) and Director of Emergency Services, Adult Emergency Department #2 (Director) stated when the ED was in a lockdown status a registered nurse (RN) or EMT would be posted with the security officer at the ambulance bay and ED reception area. According to Director #2 the RN or EMT would gather medical information for the patients. However, there was no evidence an EMT or RN was posted with HS #3 during the lockdown on 3/22/18. During a subsequent interview, on 5/2/18 at 10:00 a.m., Director #2 stated she was aware of the alleged EMTALA violation. She stated her understanding was the security officer tried to get the patient to talk with the EMT and it had not been communicated to the EMT that there was a patient with chest pain. According to Director #2 there were no intentional barriers to the patient being evaluated but they could have communicated better. Subsequently, the patient left the ED and was driven to another acute care hospital where he was admitted with a myocardial infarction (heart attack) and underwent an emergent cardiac catheterization (a procedure used to diagnose and treat cardiovascular conditions) for treatment.
Building A-1 - Main Hospital Through observation, during the survey, March 13, through March 20, 2018, it was determined that the facility failed to maintain the fire ratings on the structural beams as required. During the walk through of the facility, with the Maintenance Staff, the facility failed to mintain the monocoat system on the structural beams to maintain a 2 hour fire rating on the beams. The monocoat was missing in the following areas: 1) One beam at center of room on the 7th floor 2) Four spots by smaller elevator control room on the 7th floor 3) Two areas in the Garden level mechanical room This deficiency effected 2 smoke compartments throughout the facility.
Building A-1-Main Hospital Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to continuously maintain the means of egress free of all obstructions or impediments to full instant use in case of fire or other emergency. During the walkthrough of the facility, with theMaintenance Staff, items were being stored in the corridor that prevented the corridor from being clear and unobstructed and did not meet the exceptions in the Life Safety Code. The following areas were observed: 1) Four trash cans located in ED exit vestibule 2) Storage of clothing outside of gift shop including our clotches racks and a table of gifts. 3) Table in main corridor outside 1st floor elevators protrudes into the corridor more than 6. 4) Education office had 2 rolling carts in the path of egress-please maintain a 48 walkway to exits from the suite NOTE: All deficiencies were corrected by moving the items or storing items in different areas during the survey. These deficiencies effected four smoke compartments and four different egress paths throughout the facility.
Building A-1-Main Hospital Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility had not maintained the exit access door from being locked. During the walk through of the facility, with the Maintenance Staff,, doors contained locks on the doors or did not release on fire alarm activation as required. The following doors were efeeceted: 1) Exit door from the Decontamination room has a lock from the inside which prevented the door from opening from the inside. 2) Door to Labor and delivery is keyed access only from 2A to 2E. This locked door creates a dead end corridor greater than 50'. 3) Doors to end stairs on 6200 and 6300 did not unlock during the fire alarm test-they stayed in delayed egress mode and did not release on fire alarm activation. Note: The delayed egeress doors on 6200 were corrected during the survey. 4) Two doors located in the emeregncy department contained locked doors for security of patients. When a nurse was asked by the surveyor if she could open the door, her response was Only the security officer has a key. Note: The locks were removed from these doors during the survey These deficiencies effected one stairwell egress, one corridor, and one room within the hospital.
Building A-1 - Main Hospital Through observation and record review during the survey, March 13 through March 20, 2018, it was determined the facility failed to test the fire doors per NFPA 80 as required. During the record review, with the Maintenance Staff, the records for four fire doors could not be located indicating that they had been tested within the past year, the last inspection report on record was dated February 28, 2017. 1) Main lobby horizontal sliding fire door 2) Two Vertical drop down doors at the Cafateria 3) Vertical sliding door at blood bank area These deficiencies potentially effected 3 smoke compartments.
Building A-1 - Main Hospital Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to maintain the kitchen extinguishing system as required. During the walk through of the facility, with the Maintenance Staff, the extinguishment nozzles over the deep fryers in the main serving area were not covering the deep fryers adequately. The fryers were placed to the right of the extinguishment nozzles. This deficiency effected 1 smoke compartment.
Building A-1 - Main Hospital Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly. During the walkthrough of the facility, with the Maintenance Staff, the alcohol based hand rub dispensers (ABHR) were installed above or adjacent to an electrical source in two locations. Those areas are listed below: 1) Located above an in wall nite light in room #LDR 10 2) Located above wave open sensor in hybrid Operting Room Note: All deficiencies listed above were corrected during the survey These deficiencies effected 2 patient care rooms throughout the hospital.
Building A-1 - Main Hospital Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to install and maintain the fire alarm system with approved components, devices or equipment in accordance with NFPA 72. During the walk through of the facility with the Maintenance Staff, the following smoke detectors were placed within three feet (3') of the air inlet or exhaust diffuser: 1) At nurse station across from room 6214 (# ) 2) At nurse station at 4100 wing 3) At 2C smoke barrier door 4) At smoke barrier doors to 1J 5) At smoke barrier 1B 6) One located within the laboratory 7) At Physical Therapy vestibule 8) One located in Infusion hallway outside soiled hold room 9) In sterile core of Main Operating Rooms Note: All of the above were corrected during survey with the exception of #9 These deficiencies potentially effected 9 seperate smoke compartments
Building A-1 - Main Hospital Through a review of the records and discussions with staff during the survey, March 13 through March 20, 2018, it was determined that the facility failed to have the sensitivity test recorded every two years as required. During the review of the facility records, with the Maintenance Staff, the sensitivity records were not available for inspection. Note: The sensitivity test was sent to the inspector the day after the exit interview. This deficiency potentially effected the entire hospital.
Building A-1 - Main Building Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to provide smoke detectors in all areas open to the corridor. During the walk through of the facility, with the Maintenance Staff, the facility failed to provide smoke detector coverage in all areas which were open to the corridor in the following areas: 1) Nutrition area across from room #5212 2) Nutrition area across from room #4212 3) Nutrition area across from room #3214 These deficiencies potentially effected three smoke compartments within the facility.
Building A-1 - Main Hospital Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to install an automatic sprinkler system per NFPA 13. During the walk through of the facility, with the Maintenance Staff, it was determined that a soffit area, located on the second floor in compartment 2D (between rooms 2202 and 2218), failed to have sprinkler coverage as required. The soffit measured approximately twenty four inches (24) deep and did not have coverage from the adjacent sprinklers. This deficiency effected one smoke compartment.
Through observation during the survey, March 13 through March 20, 2018, it was determined the facility failed to maintain the doors to the corridor. During the walk through of the facility with the Maintenance Director, corridor doors did not positively latch, were held open by a door wedge, or failed to maintain any type of latching mechanism. The following doors were effected: 1) Closet door adjacent to room 5107-has a left leaf with a manual lock 2) Left leaf of closet door adjacent to 4310 will not latch-corrected during survey 3) Closet door would not latch at 3rd floor nurses station--corrected during survey 4) Closet door adjacent to ED room 5 has a roller latch 5) Door to floor 4 dictation room propped with door wedge, no smoke detector in space. Door wedge removed during survey 6) STJ waiting room measures approx 1400 sq. Ft with another waiting area at 432 square feet in size. The corridor runs in between the two waiting rooms. There were three (3) sliding doors, located at the reception check in desks, that did not contain any type of latching mechanism on the doors. These deficiencies potentially effected six smoke compartments.
Building A-1 - Main Hospital Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to maintain the smoke barrier walls to a one hour rating. During the walk through of the facility, with the Maintenance Staff, the smoke barrier walls in three locations contained blow out patches to seal large holes. The locations are as follows: 1) Electrical room on 3rd floor 2) Above rated doors to 5C 3) Soiled utility room conduit side on 1st floor These deficiencies effected 6 smoke compartments throughout the facility.
Building A-1 - Main Hospital Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to maintain the smoke barrier doors. During the walk through of the facility, with the Maintenance Staff, smoke barrier doors failed to close properly in the following areas: 1) Zone 5A 2) Zone 4A 3) Zone 2B 4) Zone G-E 5) Zone G-C Note: All doors were corrected during the survey These deficiencies potentially effected ten smoke compartments throughout the hospital.
Building A-1 - Main Hospital Through record review during the survey, March 13 through March 20, 2018, it was determined the facility failed to test smoke dampers the first year after they were installed. During the review of the records, with the Maintenance Staff, documentation was not available to indicate that three (3) smoke dampers, that had been replaced in February 2017, had been tested the one year after installation. The three smoke dampers were: 1) ID# 3 Endoscopy corridor 2) ID# 5 Inside OR equipment storage 3) ID # 8 Inside Hybrid OR These deficiencies potentially effected 3 smoke compartments.
Building A-1 - Main Hospital Through observation during the survey, March 13 through March 20, 2018, it was determined the facility failed to divide the essential electrical system onto the correct branches per NFPA 99. During the walk through and observation, with the Maintenance Staff, the electrical box contained two (2) items named Fire Alarm TBS located on the criticial branch of the electrical panels in the 2nd floor LDS room. Unknown what the Fire Alarm RBS circuits are for and if they are part of the fire alarm system or another system. The electrical supervisor was on vacation and these items could not be determined what they were for during the survey. The deficiency potentially effected one floor of the building.
Building A-1 - Main Hospital Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to maintain the generator batteries as required per NFPA 110, section 8.3.7.1. During the record review, with the Maintenance Staff, the generator battery conductive testing had not been completed monthly as required. This deficiency potentially effected all staff and patients.
Building A-1 - Main Hospital Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to maintain the electrical system in accordance with NFPA 70. During the walk through of the facility, with the Maintenance Staff, an extension cord was plugged into a powerstrip in the Education Office area. Note: The 50' extension cord was removed during the survey. This deficiency potentially effected one smoke compartment.
Building A-3 - Pediatric Emergency Through observation, during the survey, March 13, through March 20, 2018, it was determined that the facility failed to maintain the fire ratings of the occupancy separation. During the walk through of the facility, with the Maintenance Staff, there was one (1) unsealed pipe conduit above the second (2nd) exit door. Note: This deficiency was corrected during the survey
Building A-3 - Pediatric Emergency Through observation, during the survey, March 13, through March 20, 2018, it was determined that the facility failed to maintain the fire ratings on the structural beams as required. During the walk through of the facility, with the Maintenance Staff, the facility failed to maintain the monocoat system on the structural beams to maintain a 1 hour fire rating on the beams. The beam was missing monocoat in the middle of the long corridor. This deficiency potential effected one smoke compartment.
Building A-3 - Pediatric Emergency Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility failed to install the Alcohol Based Hand Rub (ABHR) dispensers correctly. During the walkthrough of the facility, with the Maintenance Staff, the alcohol based hand rub dispensers (ABHR) was installed above an electric push to open button at the second (2nd) exit. Note: This deficiency was corrected during the survey. This deficiency effected 1 smoke compartment
Building A-3 - Pediatric Emergency Through observation during the survey, March 13 through March 20, 2018, it was determined that the facility had not maintained the doors to the corridor as being smoke resistive. During the walk through of the facility, with the Maintenance Staff, the door to exam room #1 contained a gap, when closed, which was greater than 1/2 thick which prevented the door from being smoke resistive. This deficiency effected 1 smoke compartment.
Based on record review and interviews, the facility failed to ensure 1 of 1 patients on an mental health hold received a mental health evaluation prior to discontinuing the mental health hold (Patient #2). Findings include: The policy, Behavioral Health Suicide Risk Assessment and Care of the Suicidal Patient read, disposition of a patient will be determined by the Psychiatrist and/or LCSW in consultation with the medical team. A patient at risk for self-harm will be reassessed and this assessment will be documented once per shift by the registered nurse. Patients who are no longer deemed at risk for self-harm will be evaluated by a physician who will provide the appropriate orders to decrease protective measures. The policy, Mental Health Hold read, discontinuation of a M-1 hold read, in order to discontinue a M-1 hold, the physician must place an order to do so in the medical record. There must be accompanying documentation by the physician that stated the reason the hold has been discontinued. Without this order and documentation, the M-1 hold remains active. 1. The facility failed to ensure a patient deemed an imminent danger to himself and placed on a mental health hold was evaluated by a physician prior to discontinuing the mental health hold. a. Review of the medical record revealed Patient #2, was brought in to the emergency department on 3/10/18 at 10:35 a.m. by emergency medical services after an attempted suicide. At 12:15 p.m., Patient #2 was placed on a mental health hold (M1 hold) by the emergency department physician after it was determined the patient was an imminent danger to himself. According to the M1 Hold documentation, Patient #2 jumped off a second level tier (15 feet) with the intent to kill himself. At 3:50 p.m., Patient #2 was transferred to the Intensive Care Unit (ICU) with the M-1 hold still in place. At 3:55 p.m., the critical care physician documented in the progress note, Patient #2 reported stress but denied suicidal ideations (SI). The physician then documented in the diagnosis, assessment and plan section of the progress note under SI: M1 hold and psychiatry consulted. At 8:34 p.m., a verbal order, by a Registered Nurse (RN), was documented to discontinue the M-1 hold and signed by Physician #2. On review of the medical record for Patient #2, there was no documentation of an evaluation by a physician as to the reason the hold had been discontinued, to include Physician #2, prior to discontinuing the M-1 hold. This was in contrast to facility policy. On 3/11/18 at 7:30 a.m., 11 hours after the M1 hold was discontinued via a verbal order, Physician #1 completed a psychiatric examination. On 3/11/18 at 10:02 a.m. in an addendum to the psychiatric progress note, Physician #1 discontinued the M-1 hold. b. On 3/14/18 at 4:00 p.m. an interview was conducted with the ICU manager (Manager #3). Manager #3 stated a M1 Hold was a psychiatric hold placed if a patient was deemed as harmful to themselves or the community. Manager #3 stated a M1 hold was for the safety of a patient who was deemed incapable to make decisions for themselves. Once placed on a M1 hold, the patient must be observed by staff until the patient was evaluated by appropriate personnel and deemed capable to make decisions for themselves. c. On 03/14/2018 at 11:41 a.m. an interview was conducted with the Physician #1. Physician #1 stated he was unaware a RN had placed a verbal order in Patient #2's medical record to discontinue the M-1 hold. Physician #1 stated a verbal order to discontinue a M1 hold was not appropriate as a face to face, by a licensed professional qualified to evaluate the patient, was required prior to discontinuing the hold. The evaluation, according to Physician #1 would include an assessment of what measures were in place to maintain the patient's safety and an evaluation of the patient, including evaluation for psychosis (a mental disorder in which thought and emotions are impaired), needed to be present. d. On 03/14/18 at 5:04 p.m., a joint interview was conducted with Chief Medical Officer (CMO) #4 and Physician #2 (via telephone). Physician #2 who signed the verbal order to discontinue the M1 hold, confirmed he was not involved in Patient #2's care and did not conduct a face to face evaluation of Patient #2 prior to the discontinuation of the M1 hold.
Based on the onsite validation suirvey, completed March 13 through March 20, 2018, the facility failed to comply with the regulations set forth for Life Safety and, therefore, deficiencies were cited under Life Safety Code tags K0161, K0211, K0222, K0300, K0324, K0325, K0341, K0345, K0347, K0351, K0363, K0372, K0374, K0521, K0911, K0918, K0920, and on Bldg A-3 deficiencies K0131, K0161, K0323, and K0363. See survey event ID #SKFC21 for full details of the cited deficiencies.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and record review the facility failed to reassess discharge plans for changes which potentially warranted adjustment to the plan. Specifically, staff failed to reassess a patient's oxygenation and urination status in 1 of 10 patients reviewed (Patient #3). Furthermore, the facility failed to provide a discharge summary in 3 of 10 charts reviewed (Patients #3, #7 and #10). This failure created the potential for patients to be discharged without addressing their physical needs, the appropriateness of the discharge plan and without the continuity of the plan of care post discharge. FINDINGS POLICY According to the policy, Indwelling Urinary Catheter Insertion, Maintenance, Irrigation and Removal Procedures, after removal, monitor patient for incontinence, problems voiding, or any signs of infection. According to the policy, Oxygen Protocol, the following objectives will be utilized in the determination of appropriateness of oxygen therapy, SaO2/SpO2 less than 90%. When the SaO2 is borderline with the patient breathing room air, 89-90%, the patient will be ambulated to determine oxygen requirements with activity, unless contraindicated. Portable oxygen is suggested if indicated. According to the policy, Chain of Command, employees shall follow proper communication channels to assure appropriate delivery of safe, effective patient care. After alerting department director or manager/designee of physician non-response, contact as appropriate the following order until medical staff care/assistance is available: Attending or partner covering, Nursing supervisor, department chair, Medical staff president, Chief medical officer or designee. Complete an occurrence report of all incidents of non-response. According to the policy, Discharge Planning, all patients and his/her significant others will be ensured appropriate, effective discharge plans while using proper utilization of resources. All patients are provided discharge instructions regardless of their post discharge placement setting. The patient's nurse is responsible for coordinating routine patient discharges and making referrals to appropriate ancillary services. For patients not initially identified as in need of a discharge plan, changes in the patient condition may then warrant a discharge planning evaluation. Continual case management, nursing, ancillary, and physician assessments through the patient's stay prompts adjustments to the discharge plan. The discharge plan includes knowledge necessary for the patient and/or family to meet ongoing healthcare needs. The discharge summary, written by the physician, includes the following: the reason for hospitalization , significant findings, procedures performed and care, treatment, and services provided, patient's condition at discharge, information given to the patient and family as appropriate. REFERENCES According to the Rules & Regulations of the Medical Staff as approved by the Governing Board on April 22, 2003 and subsequently amended, the last amendment having been approved August 28, 2015, a discharge summary must be recorded for all patients. According to, Algorithm for Bladder Scanning and Action Based on Results of Bladder Scan, the registered nurse (RN) will reassess within 6 hours after straight catheterization times one and notify attending physician if patient continues to have volume greater than 100 milliliters (ml), document process and physician direction in the medical record. 1. The facility failed to assess whether Patient #3 required home oxygen to be ordered upon discharge from the facility. a) Record review revealed Patient #3 was admitted on [DATE] for spinal surgery and discharged 4 days later on 07/31/17. The patient's history showed no documentation of oxygen use at home. According to the respiratory charges, Patient #3 received oxygen on 07/28/17, 07/29/17 and again on 07/30/17. According to the pulse oximetry (pulse ox) readings for Patient #3, on 07/29/17 from 4:48 a.m. until 5:00 a.m., the patient's pulse ox reading remained at 84-85%. According to the pulse ox reading on 07/30/17 from 4:39 a.m. until 4:45 a.m., the patient's pulse ox reading remained at 82%-85%. According the vital sign record on 07/31/17 at 7:52 a.m., the patient's pulse ox reading was 89% while on room air (RA). The patient was discharged at 3:19 p.m. without an evaluation to determine in home oxygen was required. b) On 10/25/17 at 3:58 p.m., an interview was conducted with Registered Nurse Manager (RN) #3 who had oversight of nursing staff at the facility and had been assigned to care for Patient #3. RN #3 confirmed no further interventions related to the patient's pulse ox status were documented. This was in direct contrast to facility policy which stated oxygen was a prescribed drug and a pulse ox of less than 90% would be utilized in the determination of the appropriateness of oxygen therapy. c) On 10/26/17 at 10:54 a.m., an interview was conducted with RN #4, who stated s/he worked as a Charge Nurse on the unit Patient #3 was hospitalized on. After review of Patient #3's pulse ox on 07/31/17 at 7:52 a.m. with a reading of 89%, RN #4 stated the expectation would be to notify the physician and have the patient ambulate on room air to test for de-saturation (a decrease in oxygenation). RN #4 stated there was no documentation of either in the patient's medical record. d) On 10/25/17 at 2:16 p.m., a joint interview was conducted with Respiratory therapist (RT) #1 and RT #2. A review of Patient #3's chart was completed and RT #1 confirmed Patient #3 received oxygen for 3 nights, from 07/28/17 - 07/30/17 while hospitalized . After a review of Patient #3's pulse ox readings for 07/29/17 and 07/30/17, RT #1 stated Patient #3 should have had home oxygen (O2) therapy ordered and confirmed the patient had no orders for home O2. RT #1 stated oxygenation was important as it provided air to the lungs and heart and then the rest of the body and was vital to preserving the patient's brain tissue. e) On 10/26/17 at 9:07 a.m., an interview was conducted with Physician #6, who had provided care for Patient #3 during the hospitalization . Physician #6 stated if a patient's pulse ox was below 88% the patient would possibly require home oxygen. Physician #6 stated s/he would have expected to receive a phone call to discuss the patient's pulse ox. 2. The facility failed to ensure Patient #3 was safe to be discharged from the facility upon removing his/her foley catheter. a) On review of Patient #3's medical record, a foley catheter (flexible tube placed through the urethra and into the bladder to drain urine) was placed on 07/28/17 at 12:50 p.m. and removed on 07/31/17 at 12:56 p.m. There was no further documentation the patient was monitored or urinated after the foley catheter was removed and prior to his/her discharge. Furthermore, there was no documentation the patient or family was instructed on post foley monitoring or signs and symptoms of complications. b) On 10/25/17 at 3:58 p.m., an interview was conducted with RN #3 who confirmed removing the patient's foley catheter and discharging the patient. RN #3 confirmed there was no documentation the patient urinated after the foley catheter was removed and no documentation the patient or family was instructed on post foley monitoring or signs and symptoms of complications. RN #3 stated it was physician preference whether a patient would stay at the facility to be monitored after the foley catheter was removed and stated patients had been sent home before without monitoring. This was in direct contrast to facility policy. RN #3 stated the risks of not urinating after foley catheter removal would be the patient's bladder would continue to fill with the bladder overstretched and could lead to damage. c) On 10/26/17 at 10:54 a.m., an interview was conducted with RN #4 who stated the expectation after removal of a foley was to verify the patient urinated. RN #4 stated it was important to verify post foley removal, due to the potential of urinary retention and infection, which was hospital policy. On review of Patient #3's medical record, RN #4 stated there was no documentation Patient #3 urinated after the removal of the foley and prior to discharge. d) On 10/26/17 at 9:07 a.m., an interview was conducted with Physician #6 who stated the expectation for all patients after foley removal would be to monitor the patient and verify the patient urinated. Physician #6 stated if there was no urination s/he expected staff to follow hospital protocol for bladder scanning. 3. The facility failed to ensure Patient #3 was discharged in a timely manner. a) Review of Patient #3's medical record revealed on 07/30/17 an orthopedic surgery note stated the Patient #3 may discharge home if cleared by medicine. On 07/30/17 at 2:46 p.m. a Nursing Note stated a call to the medicine physician was attempted twice to discuss possible patient discharge today with no answer. On further review of Patient #3's medical record there was no further documentation in the medical record documenting another physician was contacted to clear the patient for discharge. This was in direct contrast to the facilities chain of command policy which stated if unable to contact a physician the next person to contact would be the nursing supervisor. b) On 10/26/17 at 9:42 a.m., an interview was conducted with RN #5 who stated s/he had attempted to contact Physician #6 on 07/30/17 with no answer. RN #5 stated Physician #6 worked alone and there would not have been anyone else to contact to discharge the patient. RN #5 was unaware of the facility's chain of command policy. c) On 10/26/17 at 10:54 a.m. an interview was conducted with Charge RN # 4. On review of Patient #3's medical record RN #4 confirmed Patient #3 was held awaiting Physician #6's medical clearance for discharge. d) On 10/26/17 at 9:07 a.m., an interview was conducted with Physician #6 who had provided care for Patient #3. Physician #6 stated Patient #3 had been cleared for discharge by him/her on 07/30/17 but stated the medical record lacked the appropriate documentation of medicine clearance for discharge. 4. The facility failed to ensure a discharge summary was recorded for all patients. a) Review of Patient #3's medical record revealed s/he was admitted on [DATE] for spinal surgery. The patient was admitted to the facility for a total of 4 days and was discharged on [DATE]. On review of Patient #3's medical record, no discharge summary was noted. Review of Patient # 7's medical record revealed s/he was admitted on [DATE] for spinal surgery. The patient was admitted to the facility for a total of 4 days and was discharged on [DATE]. On review of Patient #7's medical record, no discharge summary was noted. Review of Patient #10's medical record revealed s/he was admitted on [DATE] for hip surgery. The patient was admitted to the facility for a total of 2 days and was discharged on [DATE]. On review of Patient #10's medical record, no discharge summary was noted. b) On 10/26/17 at 12:04 p.m., an interview was conducted with the Chief Medical Officer (CMO #7). On review of Patients #3, #7 and #10's medical records, CMO #7 confirmed all three medical records lacked a discharge summary as required by policy. CMO #7 stated the importance of the discharge summary was to summarize the care provided to the patient during their stay at the facility and was a way to provide continuity of care for the patient to be used by external facilities. CMO #7 stated the discharge summary included a summary of the care provided along with any medications and medication updates for the patient. CMO #7 stated s/he was unsure why a discharge summary had not been completed for the 3 patients.
Based on interviews and document review, the facility failed to comply with the Medicare provider agreement, as defined in º489.24, related to Emergency Medical Treatment and Active Labor Act (EMTALA) requirements. FINDINGS: 1. The facility failed to meet the following requirements under the EMTALA regulation: Tag A2405 - emergency room Log Based on interviews and document review, the facility failed to maintain a centralized log that contained accurate information and allowed the facility to track the care provided for patients who presented to the facility for emergency services. Specifically, pediatric patients who presented to the adult emergency department (ED) seeking emergency medical care were transferred to the pediatric emergency department. The facility failed to maintain a centralized log which tracked and reflected the accurate time pediatric patients arrived at the facility seeking emergency treatment for 8 of 8 pediatric records reviewed for pediatric patients who presented to the adult ED (Patients #1, #6, #7, #8, #9, #10, #11, and #23). This failure resulted in the facility not being able to track patients' emergency care from the point when the patient initially arrived at the facility's adult Emergency Department (ED) seeking emergency treatment to when the patient arrived at the pediatric ED.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and document review, the facility failed to maintain a centralized log that contained accurate information and allowed the facility to track the care provided for patients who presented to the facility for emergency services. Specifically, pediatric patients who presented to the adult emergency department (ED) seeking emergency medical care were transferred to the pediatric emergency department. The facility failed to maintain a centralized log which tracked and reflected the accurate time pediatric patients arrived at the facility seeking emergency treatment for 8 of 8 pediatric records reviewed for pediatric patients who presented to the adult ED (Patients #1, #6, #7, #8, #9, #10, #11, and #23). This failure resulted in the facility not being able to track patients' emergency care from the point when the patient initially arrived at the facility's adult Emergency Department (ED) seeking emergency treatment to when the patient arrived at the pediatric ED. FINDINGS: 1. The facility failed to maintain a complete and accurate central log of pediatric patients who presented to the adult ED. a) Review of the Patient Through Put Flow Chart, for pediatric patients who arrived to the adult ED, revealed the patient was to receive a triage and assessment by an adult ED Registered Nurse (RN) or Emergency Medical Technician (EMT). Based on the assessment, the adult ED Physician or Physician's Assistant (PA) would perform a medical screening exam (MSE) if the pediatric patient was unstable. If the patient was stable to transfer they would be transferred to the pediatric ED b) On 09/13/16 at 9:10 a.m., an interview was conducted with Emergency Medical Technician #4 (EMT) who stated s/he did not enter pediatric patients in the computer system when they first presented to the adult ED. EMT #4 stated s/he would fill out the pediatric assessment form, obtain the patient's vital signs, and fill out the assessment list. EMT #4 stated a Registered Nurse (RN) would review the form and then determine if the pediatric patient would stay at the adult ED or transfer to the pediatric ED. EMT #4 stated the purpose of the quick evaluation was to determine if the patient should stay or go to go to the pediatric ED. When asked if there was a way to know what time the patient presented to the facility's adult ED for emergency treatment; s/he stated there was not a way to determine the time. S/he stated there was not a way to confirm the RN assessed the patient or what time the patient arrived by looking at the form. c) Review of the Pediatric Quick Screen forms, dated 05/01/16 through 09/12/16 and used to track pediatric patients who presented to the adult ED, showed no evidence a RN reviewed the form, evaluated the patient, and determined the pediatric patient was stable to be transferred to the pediatric ED. Additionally, there was no documentation as to what time the patient presented to the Adult ED for treatment. d) Medical record review showed the central log failed to accurately track the care provided to pediatric patients who presented to the adult ED. i) Review of the central log showed pediatric Patient #1 arrived on 08/15/16 at 10:13 a.m. with altered mental status. This time indicated when the patient arrived at the pediatric ED. However, review of Patient #1's medical record showed an emergency note, documented by RN #6 at 10:45, which stated the patient was brought over from the adult ED. According to the note, upon arrival to the pediatric ED, the patient was pale, pupils noted to be pin point, heart rate was 80, minimal response, and unable to answer any questions. Review of the medication administration record, at 10:25 a.m., showed Patient #1 was administered intravenous Narcan, a drug to treat narcotic overdose in an emergency situation. Review of the medical record showed the patient (MDS) dated [DATE] at 10:13 a.m. and was triaged at 10:15 a.m. RN #10 documented the parent of the child (POC) felt uncomfortable taking the patient home after being discharged a short time earlier from another facility after surgery. The POC noticed as s/he placed the patient in his/her car that the child was unresponsive and diaphoretic and decided not to take the patient home. According to the RN's assessment during the pediatric ED triage, the patient was responsive only to pain, diaphoretic and pale. The patient was four years old. Review of Patient #1's Pediatric Quick Screen form, dated incorrectly as 08/16/16, showed no documentation of the patient's arrival time at the adult ED. The screening tool showed the patient was brought in to the adult ED for post-op diaphoretic. This failure resulted in an inaccurate centralized log and did not allow the facility to track the pediatric patients' care once s/he presented with an emergent medical condition to determine if treatment was timely or delayed. ii) Review of the central log showed pediatric Patient #6 (MDS) dated [DATE] at 11:42 p.m. for syncope, a temporary loss of consciousness. This time indicated when the patient arrived at the pediatric ED after being brought over by adult ED personal. Review of the Pediatric Quick Screen, completed by the adult ED, did not show the time Patient #6 arrived in the adult ED requesting emergency treatment. There was no documentation the patient's vital signs were assessed or that the patient was assessed by a RN prior to being directed to the pediatric ED. The only information documented on the form was the patient's name, date of birth, and chief complaint. Patient #6's medical record showed the pediatric patient was admitted on [DATE] to the pediatric ED at 11:42 p.m. for syncope. There was no evidence in the medical record showing the time the pediatric patient presented to the adult ED for emergency care and that s/he was assessed and triaged by nursing staff prior to being transferred to the pediatric ED. On 09/12/16 at 3:21 p.m., an interview was conducted with Director #1 who reviewed Patient #6's medical record and the Pediatric Quick Screen. Director #1 stated there was no way to know whether an EMT or RN completed the form. Director #1 further stated there was no way to know what time the patient initially presented to the Adult ED for emergency care and that the patient was assessed prior to transfer by reviewing the form. Director #1 stated previously, the patient's arrival time was entered in the computer when the pediatric patient presented to the Adult ED. Director #1 stated the processed changed as pediatric physicians were concerned because it could show up to a 20-minute delay during transit from the Adult ED to the Pediatric ED. Director #1 stated the Pediatric Quick Screen was not considered part of the patient's medical record. Similar findings were found for Patients #7, #8, #9, #10, #11, and #23 in which the centralized log only reflected the arrival time the patients presented to the Pediatric ED, not the actual time when the patient presented to the facility for emergency treatment. e) On 09/14/16 at 3:09 p.m., an interview was conducted with Director #5 who stated s/he reviewed the Pediatric Quick Screen form to track percentage of pediatric patients who presented to the ED. Director #5 stated s/he was the one who documented the dates on the form and there was no current monitoring process ensuring the forms were completed entirely when pediatric patient presented to the Adult ED.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observations, interviews and document review, the facility failed to ensure nursing staff administered patient medications according to physician order and per the recommended dosing guidelines. Additionally, the facility failed to ensure nursing staff safely handled multiple-dose medications to reduce the risk of infection associated with the medication administration. This failure created a potential for negative patient outcomes related to unsafe medication administration. FINDINGS: POLICY According to the policy, Pediatric Medication Administration, the Registered Nurse (RN) reviews each new medication order entered by the provider/pharmacist for accuracy and completeness, including correct dose. The right medication will be administered in the right dosage, at the right time by the right route to the right patient. According to the policy, Multiple-dose/Single-dose Vial, the use of a multiple-dose vial should be limited to only a single patient, whenever possible, to reduce the risk of contamination. REFERENCE According to Micromedex, for short-term pain, the Ketorolac IV dosage recommendation for patients younger than 65 years of age is 30 mg IV as a single dose or 30 mg IV every 6 hours. 1. Nursing staff did not administer physician ordered medications to Patient #12. a) Review of Patient #12's medical record revealed the patient presented to the Pediatric Emergency Department (ED) on 08/01/16 via ambulance after ingesting another family member's medication. Patient #12 was [AGE] years old. According to the physician's notes documented at 4:35 p.m., the patient had a fever upon arrival to the Pediatric ED. At 5:07 p.m., a RN assessment was conducted by RN #10. Patient #12's documented temperature was 103.7 Fahrenheit. At 5:15 p.m., the patient's documented temperature was 100.2; then at 6:10 p.m., his/her temperature was documented as 101.4. At 4:47 p.m., Patient #12's physician ordered acetaminophen, a medication used to reduce fever, to be given to the patient. Additionally, the physician ordered for nursing staff to administer 500 milliliters of Normal Saline 0.9% intravenous (IV) fluids through Patient #12's IV catheter. There was no evidence in Patient #12's medical record showing both medications were administered as ordered. Patient #12 remained febrile upon transfer to another facility. b) On 09/14/16 at 11:52 a.m., an interview was conducted with RN #6 who stated if a medication was ordered, then nursing staff were expected to document the administration. RN #6 stated if the parent of the child refused the medication, s/he would notify the physician and document the refusal. Patient #12's medical record lacked any evidence the patient's parents refused the physician ordered medication. c) On 09/14/16 at 3:09 p.m., an interview was conducted with the Director of Pediatrics (Director #5). Director #5 reviewed Patient #12's medical record and confirmed there was no evidence showing the normal saline IV fluids and the acetaminophen were administered to the febrile patient. S/he stated the nurse should have administered the medication since there was concern about the patient's fever. 2. Nursing staff failed to clarify a medication dose which exceeded the recommended dosage. a) Review of Patient #10's medical record revealed the patient (MDS) dated [DATE] for right flank pain. At 11:14 p.m., the physician ordered Ketorolac, a non-steroidal anti-inflammatory drug, 60 milligrams to be administered through Patient #10's intravenous (IV) catheter. According to the Medication Administration Record (MAR), RN #11 administered the IV medication to Patient #10. The MAR indicated RN #12 verified the dose given with RN #11. Patient #10 was [AGE] years old. There was no evidence in Patient #10's medical record showing either RN #11 or RN #12 clarified with the physician as to why the dose ordered was beyond the recommended dosing range indicated on the Micromedex drug summary, used by the facility. Both RN's did not ensure the physician ordered dose for the new medication was an appropriate dose to be administered. This was in contrast to policy. b) On 09/14/16 at 2:20 p.m., an interview was conducted with the Director of Pharmacy (Director #13) who provided the professional reference cited above and stated it was not recommended to give a patient 60 mg of IV Ketorolac. Director #13 stated 30 mg IV was the typical dose usually prescribed. c) On 09/14/16 at 11:52 a.m., an interview was conducted with RN #6 who worked in the Pediatric ED. RN #6 reviewed Patient #10's medical record. RN #6 stated IV Ketorolac dose was usually 15 mg or 30 mg for the big kids. RN #6 stated if s/he had concerns as to if a medication was appropriate for a patient, s/he would clarify the medication with a physician, then document the conversation. RN #6 stated s/he would also check with the pharmacy and question the 60 mg IV Ketorolac dose ordered. d) On 09/14/16 at 3:09 p.m., an interview was conducted with Director #5 who reviewed Patient #10's medical record. Director #5 stated normally 60 mg of Ketorolac would be administered via intramuscularly. Director #5 stated s/he would have questioned the dose ordered. Director #5 stated 2 nurses were required to verify the dose ordered to ensure the dose was correct. Director #5 confirmed there was no evidence in Patient #10's medical record showing nursing staff followed the process. Director #5 stated the risk of administering a wrong dose would depend on the medication. Director #5 stated some medications could affect a patient's kidneys. 3. The facility failed to ensure multiple-dose medication vials brought into patient rooms, including isolation rooms, were dedicated for single patient use or discarded after use. a) On 09/12/16 at 12:22 p.m., a medication administration observation was conducted on the 6th floor Medical Surgical Oncology Unit. RN #7 removed a multiple-dose insulin vial from the unit's automated dispensing machine (ADC), then proceeded to enter Patient A's room. RN #7 administered the prescribed dose of insulin via subcutaneous route into Patient A's abdomen. Upon exiting the patient's room, RN #7 placed the multiple-dose vial of insulin into his/her scrub pocket, then proceeded to return the medication vial to the unit's ADC. RN #7 did not disinfect the vial after s/he exited the patient's room and prior to placing the vial in the ADC. During the observation, the Director (Director #8) of the unit stated the multiple-dose insulin vials were used for multiple patients on the floor. b) On 09/14/16 at 2:00 p.m., an interview was conducted with RN #9 who stated the insulin multiple-dose medication vials were shared between patients and the vials were stored in the ADC. RN #9 stated patient medications should not be stored in scrub pockets. RN #9 stated multiple-dose insulin vials were brought into isolation patient rooms as well. c) On 09/14/16 at 2:10 p.m., an interview was conducted with Director #8 who stated the current practice was for staff to scan the insulin multiple-dose vials in the patients' room, including isolation rooms. Director #8 stated there was a potential risk of contamination of the vial and the facility was working on changing the current process.
Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation º482.55, EMERGENCY SERVICES was out of compliance. A-1103 - Standard: If emergency services are provided at the hospital, the services must be integrated with other departments of the hospital. The facility failed to have a standard process to ensure pediatric patients who presented to the adult Emergency Department (ED) for emergency services were triaged and determined to be stable prior to transferring them to the pediatric ED, which was on the other side of the hospital. Specifically, the adult emergency department failed to triage and prioritize pediatric patients in 8 of 8 pediatric records reviewed for pediatric patients who presented to the adult ED (Patients #1, #6, #7, #8, #9, #10, #11, and #23). This failure created a potential for a delay in needed patient emergency care, tests, interventions, or services.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interviews and document review, the facility failed to have a standard process to ensure pediatric patients who presented to the adult Emergency Department (ED) for emergency services were triaged and determined to be stable prior to transferring them to the pediatric ED, which was on the other side of the hospital. Specifically, the adult emergency department failed to triage and prioritize pediatric patients in 8 of 8 pediatric records reviewed for pediatric patients who presented to the adult ED (Patients #1, #6, #7, #8, #9, #10, #11, and #23). This failure created a potential for a delay in needed patient emergency care, tests, interventions, or services. FINDINGS: POLICY According to the policy, Emergency Department Assessment/Reassessment, patients arriving via the walk in entrance will be triaged and assessed. Registered Nurses (RNs) complete all patient assessments. In addition, patients who present urgently will be triaged and care will be prioritized based on presentation, chief complaint and triage category. Any walk in patient classified as emergent and/or resuscitative will be taken to the ED for exam room placement and treatment. Findings from the assessment will be documented on the ED nursing record. Pediatric Critical Findings are a child with: -Room air pulse oximetry < 90% -Symptoms of respiratory distress (tachypnea, bradypnea, apnea, retractions, grunting, audible wheeze, stridor, nasal flaring, head bobbing, sitting in tripod position, cyanotic) -Symptoms of shock (tachycardia, bradycardia, pale, cyanotic, decreased level of consciousness, weak pulses, capillary refill >2 seconds, cool extremities, hypotension, distant heart sounds) -Altered mental status (inconsolable, agitated, combative, lethargic, unresponsive, disoriented, seizure) 1. The facility failed to ensure pediatric patients who presented to the adult ED were triaged, assessed and determined stable by a RN prior to being transported to the pediatric ED which was located in another area of the hospital. a) Review of the Patient Through Put Flow Chart, for pediatric patients who arrived to the adult ED, revealed the patient was to receive a triage and assessment by an adult ED Registered Nurse (RN) or Emergency Medical Technician (EMT). Based on the assessment, the adult ED Physician or Physician's Assistant (PA) would perform a medical screening exam (MSE) if the pediatric patient was unstable. If the patient was stable to transfer they would be transferred to the pediatric ED. b) On 09/08/16 beginning at 1:15 p.m., a tour of the adult ED and the pediatric ED was conducted with the Director of the Adult ED (Director #1) and the Director of Regulatory (Director #2). Director #1 stated the distance from the adult ED to the pediatric ED was approximately 0.22 miles. During the tour, the walk from the adult ED to the pediatric ED required the use of an elevator from the first floor to the ground floor. Director #1 stated patients could be escorted through the garden if the weather was nice. During the tour, an interview was conducted with Emergency Medical Technician (EMT) #3 who stated when pediatric patients presented to the adult ED, s/he would complete the Pediatric Quick Screen assessment form and have a RN review the document once it was completed. Neither the EMT or the RN would sign the assessment tool identifying who completed the assessment. EMT #3 stated if the pediatric patients were non-emergent, the pediatric patient would be escorted with a RN to the pediatric ED. Review of the Pediatric Quick Screen assessment tool revealed the form was to used to rapidly screen pediatric patients for stability prior to transition to the pediatric ED. According to the quick screen tool the RN should complete the Pediatric Assessment Triangle, which required assessment of the patient's circulation to skin, work of breathing, and general appearance. If the pediatric patient's assessment indicated their skin was warm, pink, and dry; their breathing was even, unlabored, and no accessory muscles were used; and their general appearance was alert, active, and appropriately interacting with their parent/guardian, it was okay to move the patient to the pediatric ED as stable. If the pediatric patient's assessment indicated their skin was pale, cool, clammy; their work of breathing was stridor, grunting, with nasal flaring and use of their accessory muscles; and their general appearance was limp, lethargic, with minimal responsiveness, the patient should be seen in the adult ED. Review of the Pediatric Quick Screen forms, dated from 05/01/16 through 09/12/16 showed numerous forms had no patient assessments documented to determine if the pediatric patient was stable, including the required vital signs. Furthermore, there was no evidence a RN reviewed the forms, evaluated the patients, and determined the pediatric patients were stable to be transferred to the pediatric ED. This was in contrast to policy. c) Review of Patient #1's Pediatric Quick Screen, dated incorrectly as 08/16/16, showed the patient was brought in to the Adult ED for post-op diaphoretic. There was no documentation an Adult ED RN assessed the pediatric patient to determine if s/he was stable for transfer to the pediatric ED. The Pediatric Assessment Triangle was not completed. Additionally, there was no documentation Patient #1's respiratory rate was assessed upon arrival. Patient #1's medical record showed the patient (MDS) dated [DATE] at 10:13 a.m. and was triaged at 10:15 a.m. RN #10 documented the parent of the child (POC) felt uncomfortable taking the patient home after being discharged a short time earlier from another facility after surgery. The POC noticed as s/he placed the patient in his/her car that the child was unresponsive and diaphoretic and decided not to take the patient home. According to the RN's assessment during the pediatric ED triage, the patient was responsive only to pain, diaphoretic and pale. The patient was four years old. At 10:45 a.m., RN #6 documented an emergency note stating upon arrival to the pediatric ED, the patient was pale, pupils noted to be pin point, heart rate was 80, minimal response, and unable to answer any questions. RN #6 documented the patient was brought over from the adult ED; however, s/he did not document the time the patient presented to the adult ED. According to the medication administration record, at 10:25 a.m., Patient #1 was administered intravenous Narcan, a drug to treat narcotic overdose in an emergency situation. There was no documentation to show when the pediatric patient arrived at the facility's adult ED and that s/he was assessed and stable to transfer to the pediatric ED located in a different area of the hospital. d) Review of the Pediatric Quick Screen, dated 08/22/16, for Patient #6, completed by the adult ED, showed the pediatric patient presented with a chief complaint of syncope, which was a temporary loss of consciousness. The Quick Screen showed no documentation the patient's vital signs were assessed and that the Pediatric Assessment Triangle was completed by a RN to determine if Patient #6 was stable for transfer to the pediatric ED. The only information documented on the form was the patient's name, date of birth, and chief complaint. Patient #6's medical record showed the pediatric patient was admitted on [DATE] to the pediatric ED at 11:42 p.m. for syncope. There was no evidence in the medical record showing the time the pediatric patient presented to the adult ED for emergency care and that s/he was assessed and triaged by nursing staff prior to being transferred to the pediatric ED. On 09/12/16 at 3:21 p.m., an interview was conducted with Director #1 who reviewed Patient #6's medical record and the Pediatric Quick Screen. Director #1 stated there was no way to know whether an EMT or RN completed the form. Director #1 further stated there was no way to know what time the patient initially presented to the adult ED for emergency care and that the patient was assessed prior to transfer by reviewing the form. Similar findings were found for Patients #7, #8, #9, #10, #11, and #23 in which pediatric patients presented to the adult ED for evaluation of an emergent condition and either the Pediatric Assessment Triangle was not completed by a RN to determine if the patient was stable to transfer to the pediatric ED, vital signs were not assessed, or both. Additionally, the Pediatric Quick Screens did not identify what individual assessed the patient and determined s/he was stable for transfer and did not require immediate treatment in the adult ED. e) On 09/13/16 at 9:10 a.m., an interview was conducted with EMT #4 who stated s/he did not enter the pediatric patient in the computer system when the patient first presented to the adult ED. EMT #4 stated s/he would fill out the pediatric assessment form, obtain the patient's vital signs, and fill out the assessment triangle. EMT #4 stated the RN would review the form and then determine if the pediatric patient would stay at the adult ED or transfer to the pediatric ED. EMT #4 stated the purpose of the quick evaluation was to determine if the patient should stay or was stable to go to the pediatric ED. S/he stated there was not a way to confirm the RN assessed the patient by looking at the form. f) On 09/14/16 at 9:34 a.m., an interview was conducted with Director #1 who stated the Pediatric Quick screen forms were collected and given to Director #5. On 09/14/16 at 3:09 p.m., an interview was conducted with Director #5 who stated s/he reviewed the Pediatric Quick Screen form to track the percentage of pediatric patients who presented to the adult ED. Director #5 stated s/he was the one who documented the dates on the form and there was no current monitoring process ensuring the forms were completed when pediatric patient presented to the adult ED.
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